Sex and family planning: how we teach the young: report on a study

World Health Organization.).. Regional Office for Europe I 1-,;, Copenhagen Public Health in Europe 23 II/ Sex and family planning: how we teach the young Report on a study ., " J L C 2.. The World I lealth Organi,ation is a specialized agency of the United Nations with primary rcsponsihility for international health matters and public health. Through this Organization, which wa created in 1948, the health professions of some 160 countric exchange their knowledge and experience with the aim of making possible the attarnment hy all citizens of the world by the year 2000 of a level of health that will permit them to lead a ocially and economically productive life. The WI 10 Regional Office for Europe ts one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region has 32 active Member States,0 and is unique in that a large proportion of them are industrialized countrie with highly advanced medical services. The European programme therefore differ from those of other regions in concentrating on the problems a sociated with indu trial ociety. In 11, strategy for attaining the goal of "health for all by the year 2000" the Regional Office is arrangrng its activ1t1es in three main areas: promotton oflifcstyles conducive to health; reduction of pre\·entable conditions; and provision of care that is ade- quate. accessible and acceptable to all. The Region is al o characterized by the large number oflanguages poken by its pcopk , and the resulting difticultie in disseminating information to all who may need it. The Regional Office publi hes in four languages- English, French, German and Russian - and application for rights of translation into other languages are most welcome. a Albania, ,\ustria, Belgium. Bulgaria, Czechoslovakrn, Denmark, hnland, France, German Demo• crauc Republic. l·ederal Republic of Germany, Greece, llungary, Iceland, Ireland, lu,ly, I u,embourg, Malta. \lonaco, Morocco, Netherlands, :--orway. Poland, Portugal. Romania. San Manno, Spam. Sweden, Sw11zerland, Turkey. USSR, Unned Kingdom and Yugo l.w,a Sex and family planning: how we teach the young World Health Organization lfl-~ Regional Office for Europe ~ . . ~ Copenhagen ~ rJJ / 0'-1/3 Public Health in Europe 23 Sex and family planning: how we teach the young Report on a Study B. Lewin Department of Sociology University of Uppsa /a Sweden ICP/ MC II 024 RMl/79/ P05 ISBN 92 890 I 159 9 © Wo rld Hea lth Orga ni zati o n 1984 Publicati o ns o f th e Wo rld Hea lth Organi za ti on enj oy copyright protecti o n in ac- co rda nce with th e prov isio ns of Pro toco l 2 of th e Uni ve rsa l Co pyright Co nve nti on. For right s o f reprodu ctio n or t ra nsla ti o n, in pa rt or in 1010, of publica ti o ns iss ued by the WHO Regio na l Offi ce fo r Euro pe applica ti o n sho uld be made to the Regio na l Offi ce fo r Europe, Scherfigsvej 8, DK-2 I 00 Co penhagen 0, Denmark. The Regi o nal Office welco mes such applicatio ns. The des igna ti o ns empl oyed a nd th e prese nta ti o n of th e ma teria l in this publi- ca t io n d o no t impl y th e ex press io n of a ny o pinio n wha tsoeve r o n the pa rt o f the Sec reta ria t o f the Wo rld Hea lth Orga ni za ti o n co nce rnin g th e legal status o f an y co untry, territo ry, cit y o r a rea o r o f its auth o riti es , o r co nce rnin g th e d elimit a ti o n o f it s fro ntie rs o r bo unda ri es. The menti o n of spec ifi c co mpa ni es o r o f ce rt a in manufa cturers' p roducts does not impl y tha t they a re endo rsed o r reco mmended by th e Wo rld Health Orga ni z- a ti o n in preference to o th ers o f a simil a r na ture th a t a re no t menti o ned . Erro rs a nd o miss io ns excepted , the na mes of proprieta ry products a re distinguished by initial ca pit a l lette rs. The views ex pressed in this publica ti o n a re th ose of th e a uth o r a nd do no t necessa ril y represe nt the deci sio ns o r th e sta ted po li cy of the Wo rld Hea lth Organi zati o n. PRINTED IN BELGIU M ISSN 0300-4880 CONTENTS Page Prefa ce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v11 Acknowledgements Introduct ion .......... . ... . .. . .... . .. .. ...... . ..... ... .. . .. . Bibliography ............................... .... . ... . .. .. . . Gove rnment po licy Selected approaches Questionnaires vi ii 2 2 2 Study visit s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 I . Family plan ning a nd sex education for you ng people . . . . . . . . . . 5 Ado lescence: a transition from childhood to adu lthood . . . . . . . . . . . . . 5 Sex educa tio n: a theme with variations 7 Wha t is mea nt by fami ly planning? . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2. Official views on family planning and sex education for young peo ple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Definiti o n o f yo ung people II Famil y planning for yo ung people . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3. Approaches in selected countries . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Belgi um Federal Republic of Germa ny 27 38 Ita ly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Morocco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 The Netherl a nds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Po la nd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Po rtuga l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Sweden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Yugoslavia Summary of ra tings made in the p rojec ts and programmes stud ied 87 98 V 4. Conclusio ns a nd reco mmendatio ns Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Recomm endatio ns 105 Refe rences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Annex I . Select bib liogra ph y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 0 Annex 2. Questio nna ire to a ll gove rnments of Member Sta tes of the WHO Euro pea n Regio n . . . . . . . . . . . . . . . . . . . . . . . 132 Annex 3. Questi onna ire to se lected sex ed ucation a nd/ o r famil y pla nning progra mmes/ projec ts for yo ung peo ple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Annex 4 . Summa ry of gove rnment replies to the q uestio nna ire 158 Annex 5. Demographic da ta o n co untri es where specia l p rogra mmes/projects we re st udied . . . . . . . . . . . . . . . . . . . . 162 Annex 6. List of people met a nd institutio ns vis ited . . . . . . . . . . . . . . 168 VI Preface In most of the nations of the WHO European Region the years since the Second World War have been marked by a progressive liberaliza tion of the relations between the sexes. The reasons fo r this change are many - among them the aftermath of a disastrous war, the expansion of feminism and the ready availability of contraceptives, especially oral contraceptives - and the con- sequences promise to be great and long-lasting, not only for individuals but also for the community and the nation. Young people are deeply affected by these changes. They are less bound by traditional values and morality than their parents were, and they are aware of the greater freedom that they now have. But to what extent have they received education in sex and family life that will enable them to avoid the pitfalls of such freedom? Are governments conscious of the problems and, if they are, what steps are they taking to meet them? If governments are not taking action, do other organizations fill the gap? To clarify the situation in the European Region, WHO commissioned the author of this book to carry out a study of the sex and family planning education of young people. Nine countries were specially selected for detailed study and illustrate the variety of approaches. The study clearly demonstrates how small a proportion of young people receive instruction in a subject that will profoundly affect their future life and that of the community. It reveals the need for a more systematic approach to sex education and, more broadly, to education on family life and its problems. The findings of the study are obviously applicable not only to the WHO European Region but also to many other parts of the world. It is to be hoped that governments will study the findings with care if only because, as the study points out, it is cheaper to provide the young with adequate education on/amity planning and sex than to cope with the abortions, ruined educational oppor- tunities, and other unwelcome side effects of today's sexual freedom. t Leo A. Kaprio WHO Regional Director • for Europe VII Acknowledgements The author thanks all those persons in the countries he visited for the time they so generously placed at his disposal and the assistance they afforded him in this study. He also expresses his gratitude to his colleagues at the Department of Sociology, Uppsala University, and to staff members of the WHO Regional Office for Europe for their helpful comments. The WHO Regional Office for Europe expresses its gratitude to the United Nations Fund for Population Activities for supporting this work financially . VIII Introduction The purpose of this study is to assess the status of education in sexuality, family li ving, and family planning for adolescents and children in the WHO European Region. The study was designed to add fresh information to earlier studies and evaluations of educational programmes on sex and family living, and to increase knowledge about selected examples of various strategies in coping with these issues. Information on these matters was gathered by: the collection and organiz ing of previous studies and reports into a select bibliography: the collection of official views by means of a questionnaire sent to government agencies: the collection of information on various ap- proaches by means of a questionnaire sent to selected resource persons: and study visits. Bibliography The select bibliography of recent material dealing with family planning and the sex education of young people appears as Annex 1. It does not a im at completeness but at being a source of information to the planner as well as to the field worker trying to implement services who wishes to learn from the experience of others. The bibliography has been limited to recent material published in English, French and German . A substanti al body of information was found for the north-western part of the Region, considerably less for other parts. Most of the material relevant to the less industrialized parts of the Region (and published in any of the languages mentioned) is to be found in various WHO publications. Monographs on family planning and /or sex education for young people in some parts of the Region are missing in the bibliography. This is partly due to the requirement that a work should be published in either English , French or German in order to be included in the bibliography, partly to the overall lack of such studies. During the study visits it became evident that for a lmost a ll countries in the Region the providers are so busy providing a much-needed and much-demanded service that they have almost no time for evaluating their own work. This is regrettable , firstly because lack of evaluation makes it difficult to improve a project or programme, secondly because it is therefore a lmost impossible for service planners and providers in one country to learn from the experience of those in other countries . Service providers often expressed a wish to be able to make evaluations, publish studies, and exchange experience with other service providers . However, they were very seldom given this opportunity owing to general shortage of time and resources. Most programmes or projects work with limited funds and insufficient staff to cope with the heavy demand for services. Government policy A short questionnaire was sent to government agencies in all countries of the Region . The questionnaire appears as Annex 2. The purpose of the questionnaire was to find out to what extent any kind of sex education is compulsory or otherwise incorporated into the school sys tem and which aspects of sex education and family planning for young people are felt to be most urgent by various government agencies (generally directorates of health or the equivalent). Selected approaches To supplement what was learned about official policies, a number of countries were se lected for a survey of actual programmes. The countries were selected because it was anticipated that they had programmes of interest and that the programmes were readily accessible. A fairly detailed questionnaire was sent to the chosen projects in advance of the study visit made by the consultant. The questionnaire appears as Annex 3. The countries se lected for special case studies were Belgium, the Federal Republic of Germany, Italy, Morocco, the Netherlands, Poland , Portugal, Sweden and Yugoslavia . Questionnaires Questionnaires were employed since they were regarded as offering an economically advantageous way of collecting comparable data . Comparability was sought not only between the answers given by the government agencies in the different countries but also, to some extent, between the answers of a government agency in one country and the projects or programmes studied in the same country, since the views might not be the same for government agencies and field workers. Data gathered by questionnaires are often used for computer analysis employing elaborate statistical procedures. Owing to the limited number of cases in this study, such an analysis was not felt to be meaningful. The results from the questionnaires to governments are presented by simple frequency distributions and discussions on the characteristics of individual countries. The various programmes or projects in the selected 2 • . . .. ... ... ◄ p .. countries are discus~ed one by one. Thf ·u'se-of questionnaires. however. ensured th a t the sa me bas ic data were gathered fo r the p rogra mmes or projects. Stud y visits Since the rea lit y is usuall y mo re complex th an wha t is conveyed by answers to a ques tionnai re. it was felt necessa ry tha t the writer sho uld visit the programm es o r projec ts in the se lec ted countri es gea red in varying degrees towards the needs of yo ung people. The dual approach was used in order to provide compa rabi lit y (by means of the ques tio nn a ires) while a t the same time a llowing (by mean s of discussions during the stud y visit s) for the compl ex ity of the soc ia l setting in which the va ri o us programmes o perated . In a few instances thi s dual approac h was not possibl e. because of administrative and /o r la nguage dimculties. In those cases the report from the countries relies so lel y o n di scuss ion s and material collected during the stud y visi t. 3 1 Family planning and sex education for young people Human sexuality depends not only on biological and physiological but also on psychological and social factors. Security. self-respect. and acceptance of the self. including the body. are important prerequisites for rewarding sexual experiences. An adequate understanding of this and of the various roles played by men and women. primarily in their own but also in other societies, is necessary for the proper functioning of the individual in his or her sexual capacity, as well as in his or her capacity as partner and as father or mother. Learning how to relate to others as potential partners requires the support of the older generation. The young need to be informed about the basic biological , physio logical, psychosocial and social facts. To acquire the security and se lf-respect needed for a rewarding relationship to others as potential partners, the young need not only those basic facts but a positive reinforcement as well. Since it is in the interest of every society that its members should be secure, have self-respect, and take a responsible attitude to their sexual li fe, it is a lso in the interest of every society to prepare its members for their future sexuality. The preparation of young people for sexual life can, as wi ll be seen in this report, be achieved in a number of different ways. Because of the many different cultural traditions within the WHO European Region there can be no single way of preparing them. This , however, should not serve as an excuse for neglecting to prepare them for sexual life. Adolescence: a transition from childhood to adulthood The term adolescence is used for the period during which the individual moves from relatively sheltered childhood to the totally new status of being an adult with all the responsibilities and obligations associated with adulthood. Adolescence is thus primarily a period of transition. The process of integration into the adult world implies the learning of social roles and skills as well as the internalizing of the values of society, 5 it s norms, m ores , and percepti o ns o f the wo rld . This co mplex task usually ta kes place during the teens, altho ugh individua l and cultural va riations a re g rea t. During thi s period the individua l undergoes rapid phys ical develo pment a nd reaches reproducti ve maturit y. The biol ogical cha nges are accompanied by a psych ologica l and co gnitive development tha t , a ltho ugh inte rrela ted with the physiol ogical develo pment, is often no t simply pa ralle l; thus tensio ns a re crea ted o wing to the diffe rent stages of d evelo pment within the sa me individua l. During thi s pe riod the indi vidua l o ft en a lso leaves school and begins wo rk . T o fac il ita te the tra nsit ion to adulthood a nd minimize the problems of ado lescence. it is impo rta nt fo r the individua l to have adequa te rol e mod els. In pre-indu stri a li zed society thi s posed less of a problem since the rela tively limited differenti a tio n betwee n a nd the geogra phica l and socia l cl oseness o f ho me a nd wo rk made adult tas ks and acti vities famili a r a nd comprehensible. The socia l setting a lso us ua ll y conta ined seve ral adult s who co uld se rve as ro le mo dels. There were seve re limita tion s on th e number o f cho ices o pen to the individua l, but wh a t was expected of him o r he r wa s in ma ny respec ts almos t se lf-evident a nd he o r she was in cl ose contact with th ose with who m he o r she was to interac t la te r on as an adult . With industria liza tio n a nd urbaniza tio n the tra nsiti o n to adulthood has become inc reas ingly complex . Adequa te ro le models a re often no t eas il y ava il able . The cha nging na ture of soc iety has diminished the va lue of the prev io us gene ra ti o n as models fo r behavio ur. S ince ad olescents. themselves in a pe ri od of inte rna l change. a re ve ry often sensitive to cha nge in the society in which they li ve. they sometimes a lso exagge rate the inappropria teness o f pa rents as models fo r the ir own devel o pment. Wha t is a fact is tha t the inc reased complex it y a nd grea te r fluidit y o f socie ty lead to an impo rta nt inc rease m the number of cho ices poss ible and to a corres po nding d ec rease in wha t is se lf-evident o r '" na tural ". Thus the transi tion to adulth ood is becomin g an inc rea singly difficult tas k fo r the ado lescent. M o reove r. the ad o lesce nt today is bi o lo gica ll y mature a t a lower age th an in th e pas t. a nd the p ro longed educa ti o n o f in creas ing numbers o f ad olescent s ma kes fo r a grea ter intellec tua l ca pacity a t a yo unger age . O n the o ther ha nd. pro lo nged educa tio n mea ns longe r econo mic dependence o n pa rent s. and la bo ur p ro blems often make entry int o empl oyment unce rt a in . T o thi s must be added the fac t tha t the closes t rela ti ves in ma ny cases a rc a lso di so ri enta ted by recent soc ia l deve lo pment s. and to a la rge r ex tent than ever wo rk o ut side the home in pursuit s no t eas il y understood by a child . In the li ght of th e growing di ffic ult y fo r a child to beco me adult. it becomes eve r mo re impo rt a nt fo r soc ie ty to provide in fo rm a tio n a nd se rvices th a t fac ilit a te for the yo un g the p rocess of ma turin g int o respo nsible c it izens. 6 Sex education: a theme with variations An earlie r WHO repo rt ( /) no ted th a t sexua l ma tura tio n is a length y process . in vo lvin g the interac ti o n of bi o log ica l. psycho log ica l a nd socia l fact o rs. It begin s in ea rl y childhood a nd includes gende r identit y a nd the beginning o f sex ro les. With the o nset o f pube rt y the p roduc ti o n of sex ho rm ones result s in th e deve lopme nt o f second a ry sex cha rac te ri s ti cs . including growth o f the rep roduc ti ve o rga ns. of body ha ir. a nd of the adult body confi gura tio n . Th ese bi o logica l changes co mbine with th e psychosocia l enviro nment to produce a ra pid inc rease in sex ual inte rest a nd sexua l behav io ur. T o prepa re yo ung peopl e fo r these cha nges it is necessa ry to educa te them o n wh a t is go ing on in the ir bodies and o n the soc ia l s ignifi ca nce of these ch anges. Th e educa ti on necessa ry ca n be given ma ny na mes and be implemented in ma ny di ffe re nt ways . In some cases educa ti o na l programm es are ca ll ed ··hea lth a nd sex edua ti o n" . Oth er term s are .. sex and famil y li ving". "stud y o n sex a nd li ving toge the r" ... prepa rati o n fo r parenth ood", and .. hum a niza ti o n o f the re la ti o ns between the sexes". The term used for thi s kind o f educa ti on is o f inte res t in it se lf s ince it probably refl ect s some o f the values o f the co untry. M o re inte res ting. tho ugh. a re the content a nd o rgani za tio n o f the educa tio n . It has recently been suggested (2 ) th a t sex educati on in Europe ca n be classifi ed int o four ma rkedly diffe rent types: Trpe I - Popula1ion ed11ca1ion: ce ntred ma inl y. if no t exc lu sive ly. aro un d proc rea tion a nd strikingly antin ata li s t. It ad voca tes mo ral responsibility fo r th e demog raphic expl os ion and di sco urages hum an reproducti on. pl acing strong emphasis o n cont race pti ve use . T rpe 2- Scx l'duca lion: in th e na rrow mea nin g of the wo rd . mainl y based on a traditi ona l Swedi sh pa ttern (mid - I 960s) a nd unde rstood as a prepa ra ti on fo r sexua l life onl y. It ex ists a ut o nomously, apart fro m ma rri age a nd the fa mily. It s ma in a im is to teach effec ti ve fo rm s of ac hi evin g sensua l sa tisfa c ti on . G reat stress is pl aced o n co ntrace pti o n. a nd impo rta nce is a tt ached to a ny ph ysio logica l and psyc hosex ua l p ro bl ems which mi ght occur in sex ua l life . Type 3- Educalion jor in/er-human re/r11 io11ships and commun imlion: thi s is a mo re hum an ve rsio n of the traditi ona l .. sex educa tio n .. . linkin g bas ic in fo rm a ti on with persona l a ttitudes towa rd s the oppos ite sex. This is cha rac teri stic o f Denm a rk . Finl and . Sweden (fr om mid - 1970s) and Yugoslavia . Type 4- Preparal ion jor marriage and fam ily life. cha rac teri stic of so me socia li st co untri es and some so uth Europea n La tin culture countries (Portuga l. Ita ly a nd . to a lesse r ex tent. Fra nce) . It connects a widely viewed no ti on of sex educa ti o n with prepa ra tion fo r future ma rita l and pa rent a l wo rld s; th a t .. sex educa ti on" is onl y a co mponent of prepa rati o n fo r adult life in general. Ma rital a nd fa mil y life is see n as fa r mo re th an just the sexu a l cohabit a ti o n of two persons. and must be unde rstood in the co ntext o f societ y. In this type of educa tio n. pa re r.thood is considered to be a value. and the aim of every huma n being. This typology might be di sputed o n several grounds. One argument 7 against it is that it is unclear to what extent it is meant to be a division along one dimension or based on a combination of several dimensions . A second argument against it is that the characteristics of the various types are sometimes of such a kind that . although they correctly describe the type meant to be characterized, they do not exclude other types of sex education that could be described equally with the same characteristics. So, for instance. in Type 4 sex education is described as "only a component of preparation for adult life in general", while "marital and family life is seen as far more than just the sex ual cohabitation of two persons, and must be understood in the context of soc iety". It is doubtful whether adherents of any of the other types of sex education would disagree. On the other hand , it is probably correct that one particular type of sex education (Type 4) heavily st resses parenthood as a value and ai m of every human being. The reason for quoting this typology is that. in spite of the objections to it, it quite clearly shows the divergent types of sex education in Europe. Sex education for young people Not only does the content of sex education vary between cultures, so also do those to whom the education is offered . In some countries sex education in one form or another is given to children before they go to school ; in other countries it is given, if at all. in the form of biology courses offered to older adolescents in seco ndary schools . In thi s matter there is no si ngle way of attaining the goal of preparing young people for sexua l life. The recent WHO conference on the child and the ado lescent in socie ty ( /) made several recommend- a ti o ns it considered essen ti a l fo r the success of sex education programmes. First. sex education sho uld be broadened to famil y life ed uca tion and shou ld provide information conce rning sex roles, parental ro les. child care. and family interaction with th e aim of forming a complete and socia ll y active personality . prepared for a happy life with a partner and a so und fam il y. The emphasis of programmes. which in the past has been negative (prevention of pregnancy. prevention of sexual ly transmitted diseases). should be on the positive aspect of sexuality: planning for wanted children and achieving rewarding. loving human relationships . The conference also recommended that sex educa tio n programmes shou ld begin ear ly. be age-specific. anrl be · a continuous health promotional activity throughout the school years. They shou ld start in the family with the preschool child a nd be linked to the schoo l. What is meant by family planning? The term .. family planning .. may. owi ng to the cultural differences within the European Region. seem ambiguous. In some countries it applies only 8 to clinica l services . in o th ers va rious counsell ing and advisory services a re included. Even within one country the se rvices offered may vary considerably from o ne family pl a nning centre to another. In some countries there are seve ra l organizations offering family planning se rvices. sometimes with very different views on what constitutes family planning. In one of the countries in the Region a well informed observer summarized the attitudes of two different family pl a nning agencies by saying that , if a couple went to agency A with a contraceptive problem. they came out with a rel a tional problem: if they went to agency B with a relational problem. they came o ut with a condom . The scope of family planning has been di scussed in severa l WHO publication s. Family planning wa s d efi ned and described by a WHO expert committee in 1970 (J). Family pl a nnin g refers to practices th at help individual s o r co uples to atta in certain objecti ves; to avoid un wa nted births : to bring about wanted birth s; to regul a te th e interval s between pregna ncies: to control th e time a t which births occur in relation to the ages of the parent s; a nd to determine the number o f children in th e fa mil y . Services that make these practices possibl e include educati o n and co un sell ing o n fa mil y pla nning; the provisio n o f contraceptives ; th e man agement of infertility ; education a bout sex and parenthood ; and organizationally related ac ti viti es. s uch as genetic and ma rria ge counselling. sc reening for m a li gna ncy. a nd adoptio n services. As can be seen from thi s defi niti o n. family pl a nning should include not only the nega ti ve as pec t of avo iding unwa nted birth s but a lso the full se rvices needed to make it possibl e for a co upl e or an individual to pl an when to have children . Family planning for young people Puberty. with its importa nt biological and psychosocial changes. usua ll y ta kes place during ado lescence. These cha nges produce a rapid increase in sex ua l interest and sex ual behaviour . One form of sex ua l interest a nd behaviour is that directed towards the self. It is common for younger children to explo re their own bodies and mas turbate. This behaviour increases during puberty. Ma sturbati on in chi ldh ood a nd adu lthood is natural and healthy and sho uld not be rega rded as a form o f regress ion unless it replaces a ll o ther forms of sex ua l behaviour. Another form of sexua l interes t and behaviour that develops rapidl y during pubert y is sex ua l preference for a n o bject of spec ia l interes t. T ypicall y. in ea rl y ado lescence teenagers deve lo p close relatio nships with individuals of the sa me sex: it is normal that such re lation ships should occas iona lly include explicit homosex ual behav iour. The persi stence o f such homosex ual behaviour to the exclusion of the la te r develo pm ent of heterosex ualit y is poo rl y und erstood. but it is import ant that th e phenomenon should be recognized and acce pted. In most cases puberty invo lves th e rapid development of heterosexual 9 preferences a nd behav io ur : these have bio logica l roo ts but are pro foundl y influenced by the va lues and sta nda rds of the famil y, communit y, and sur ro unding soc iety. Cou rting behav io ur va ri es widely a mo ng the cultures a nd subcultures of the Euro pea n Region, but it usuall y progresses from gro up socia l interactio n invo lving bo th sexes to soc ia l interacti on in vo lvin g o nl y one couple and then ph ys ical int eracti on between the coupl e. The age o f first sex ual intercourse a ppea rs to be fa llin g; in many, if no t mos t. a reas o f the Regio n th e maj o rit y in bo th sexes have ex peri enced ex ua l intercou rse befo re their nineteenth birthd ay ( /). Societa l reac ti o ns to th e increase in sex ua l ac ti vity a mo ng ado lescents have va ri ed . In some countri es the specia l needs o f ado lescent s have been considered a nd specia l fa mil y pl a nning se rvices have been p rov ided . In o ther countries thi s ha s no t ye t happened . There o ught. howeve r, to be uni ve rsa l recognitio n of the need fo r such se rvices because o f the increase in ado lescent sexua l ac ti vit y and beca use adolescent s in general a re a particula rl y vulnera ble group. No t o nl y are th ere increased medical ri sks in pregnancy in yo unge r ad o lescents, but there a re al so serio us socia l effec ts from unpl anned pregna ncies. Pl a ns fo r educatio n a re o ft en ruined by too ea rl y childbea ring a nd o ft en neither the adolescent father no r the ado lescent mother is in a pos itio n to support a child socially a nd economica ll y. From numerous studies it is known tha t the use of co ntracepti ves is considerabl y less frequent a nd less regul a r amo ng ado lescents tha n amo ng adult s. The reason for thi s is sometimes lack o f kno wledge , no t o nl y abo ut co ntraceptives but a lso a bout the bas ic fact s o f reproductio n, a nd the remedy is educa tio n and still mo re educ::i tion . The use o f contraceptives is, however, low even where there has been educa ti o n a nd the ad olescent has a bas ic knowledge of reproduction and contracepti on. Educa ti on a lone is therefore no t enough; knowledge has to be transfo rmed into prac tice . The crucial fac to rs here a re ava il a bility a nd acceptability . The actua l ava il a bilit y o f fa mil y pla nning is usua ll y no t suffic ient. Fo r the teenage r to accept a nd practise fa mily pla nning he o r she no t o nl y needs kn owledge a bo ut how a nd a bo ut where to ge t contracepti ve suppl ies but must a lso accept and recognize the ad vice given and trust the people prov iding the fa mily pl anning se rvice. In ma ny cases yo ung people absta in from the use o f famil y pla nn ing and rela ted services tha t we fo rm a ll y open to them beca use, justl y o r unjustly , they fea r tha t they will be condemned mo rally or pa tronized , or tha t their sexua l activit y will be made known to pa rent s o r o ther people in their immedi ate socia l surroundings through the providers o f the services. IO 2 Official views on f atnily planning and sex education for young people The results presented in this section are based on the answers to a questionnaire (Annex 2) sent to the ministries of health in all Member States of the WHO European Region . The persons who received the questionnaire were asked to answer the questionnaire in order to help identify the official policy of the country and to give, not their personal opinion, but the official opinion. It was pointed out that, "in some instances interpretations of official documents and policies may be necessary so that the official policy can be clearly stated . We are, however, convinced that you are in a position to make such interpretations of the official policy. Since you are the only person in your country to whom these questions a re put , your cooperation is essential for the success of the study . Although we ask you to answer, you are of course free to consult others if you are uncertain about some ma tiers". It was also pointed out that some questions might see m very awkward. The respondents were then asked to remember. as should the reader, that the same questionnaire was used in all countries of the WHO European Region from the Scandinavian countries in the north to the North African countries in the south. and from the Atlantic islands in the west to the Soviet Union in the east. At the time thi s report was written completed questionnaires had been received from Algeria, Czechoslovakia (Slovak Republic), Denmark. the Federal Republic of Germany, Finland. France, Greece, Hungary, Iceland. Luxembourg, Monaco, Norway, Spain. Switzerland, the United Kingdom and Yugoslavia. Definition of young people The introduction to the questionnaire states: 11 The term YOUNG PEOPLE may seem very vague and ambiguous . This is. however. at least partially intended . Due to cultural difTerences between the countries of the Region . the age of the people referred to might difTer from one country to another . YOUNG PEOPLE should here he understood as children and adolescents helo11· the age when people in your cmmtrr usuallr marry or start to co/whit under marriage-like conditions . The legal status of sex education for young people It is claimed by 12 countries that sex education is compulsory in school. five countries reporting that it is not regulated by law. In this connexion. sex education can mean a variety of different things . France. for instance. added a comment to the question to the effect that a basic knowledge of physiology and anatomy is compulsory and that supplementary sex education is recommended but not systematically provided. Moreover. even when sex education is compulsory it does not follow that a broad education on the subject is given to all children or even to a majority of children. There are. however. no direct legal ob tacles to sex education in any of the countries: no country declared that sex education is prohibited . The absence of direct prohibition is only the first prerequisite to sex education. Where it is not regulated by law. providing it may give rise to a number of complications. In all countries it should. however. be legally possible to provide a broad sex education. Concerning the formal status of sex education one final complication should also be noted . Some countries are federations and laws concerning education vary markedly from one part of the country to another. This is so. for instance. in Switzerland . where the answer to this question was "depending on the canton" . In this case sex education in Switzerland has been counted twice. i.e .. once as not regulated by law and once as compulsory, since these were the alternatives indicated. In a survey on family planning legislation in seven Mediterranean countries Swartz ( 4) studied not only formal legislation but also the cultural background and traditions governing legal practices in Greece. Italy, Morocco. Portugal. Spain. Tunisia and Turkey . A special section in that well documented report is devoted to teenagers and family planning. What does "compulsory" mean? Those who had stated that sex education was compulsory in their countries were also asked which institutions were expected to provide formal sex education. Of the twelve countries three mentioned preschool. nine primary school. eleven secondary school. and six other schools. the latter usually meaning university or special occupational schools. Four countries also mentioned the army and eight countries other organiz- ations or institutions . In some countries sex education is compulsory in several of the institutions mentioned: in other countries only a few of the institutions provide sex education . That the secondary school is the most 12 common institution for sex education is hardly surprising: nor is it that the primary sc hool is the next most common. One organization that ought to be utilizable considerably more often is the army . Many of the countries in the Region have defence systems that require virtually all young men to be enrolled for a shorter or longer time in the army. The age of these men and the special soc ial setting. which includes exclusion of contact with women . make for the well- known phenomenon that sex and relations to women are frequent and important topics for conversation. This could be utilized for sex education much more than is now the case. In a few countries special programmes have also been developed (5. 6). That sex education is compulsory by law does not always imply that it is provided throughout the country. In some instances. and not only in the federation s. local administration is an important factor. For thi s reason the countries that had claimed sex education to be compulsory were asked whether it was possible for local governments to decide against sex education for young people in spite of its being compulsory in principle . Eight countries replied that local governments could not do so. but three countries said that sex education. although in principle compulsory. was a matter for the discretion of the local government. The extent to which various institutions within a state are self- governing is also of importance when the curriculum content is established. Countries claiming that sex education was compulsory were asked by whom the curriculum was decided . Four countries answered that it was government or national boards or general directorates of education or health. three that it wa s local government. Another four countries said that the curriculum was established jointly by government agencies. local government. and ;or the local school. That the national legislature should have passed a law making sex education compulsory in schools. and that the government should have enforced the law so that some kind of sex education is actually carried out in schools. does not mean that any broader education is necessarily given: the content of the curriculum also depends on the goodwill of local administrators. Sex education in schools requires the support of the legislature and of government agencies at national level. but the actual implementation and the content of the programme depend on the interest and cooperation of people who are active in the local community, and hence in much closer contact with the poss ible recipient s of sex education. Where local or municipal legislation exists it is at leas t theoretically possible to make sex education compulsory at the local level even if it is not compulsory at the national level. This may occur in federations . Those countries stating that there was no national law regulating sex education were asked whether local governments could make sex education compulsory for young people. None of the countries claimed that such legislation was possible at the municipal level. The United Kingdom remarked that local education authorities cannot legislate to make sex education compulsory in schools, but they may give it priority in what is taught. If this is so. in effect sex education becomes compulsory because 13 children cannot be withdrawn from it. It was. however. not known whether this had actually occurred. To whom should sex education be given primarily? Governments were asked to indicate for a number of groups whether these were felt to be important target groups for sex education. As can be seen from Table I. no other groups are so often found to be important target groups as adolescent girls and boys. This must be interpreted as indicating a fairly widespread acknowledgement of the importance of preparing young people for their future sex life. On the other hand . three of the countries did not indicate at all whether they found adolescents an important target group or not. The number of responses varied according to the number of countries that found it difficult to evaluate a certain group and so abstained from answering. Table 1. Numbers of countries answering the question: " Which of the following groups are considered by the government (or other responsible institution handling these matters. such as the national board of health education or general directorate of health/education) to be important target groups for sex education?" Target group Preschool children Children in primary school Children in secondary school Adolescent girls Adolescent boys Girls just below usual age of marriage Boys Just below usual age of marriage Newly -married women Newly -married men Women with many children M en with many children •1 = Not important at all 3 = Of some importance 5 = Very important . Number of countries indicating respective importance• 4 1 2 2 2 2 2 2 3 2 5 3 4 2 2 4 1 3 1 1 5 2 5 10 12 12 6 6 4 4 6 6 A few countries (Finland. Hungary and Yugoslavia) added a comment to the efTect that sex education should not be giwn to one group on ly but to the entire population. It would. however. be most unfortunate if the idea of providing the entire population with sex 14 educat ion shou ld prevent countries from designing special programmes for you ng people. The governments were also asked to estimate what proportion of young people leaving school had received formal sex education or any kind . The estimates \ary from 5 " .. to I 00 °.,. Unfortunately. not all co untri es answered that question (Table 2). Table 2. Number of countries estimating proportion of adolescents who had received sex education . Proportion of adolescents who had received sex education 0- 33 % 34- 66 % 67- 100 % Question not answered in questionnaire received What should be taught? Number of countries 2 1 8 5 A number of possible topics to be included in sex education of young people were li sted and governments were asked to rate how important th ose topics were in government policy. They were also asked to state whether any of the themes were compulsory in sex education or. on the o ther hand. felt to be entirely unfit for young people . The result is presented in Table 3. The table indicates that the biological foundations of sexualit y arc still the subjec ts most often considered important in sex education. Four th emes more often th an others are singled out: sexua l anat omy: reproductive biology : contraceptives: and parenthood . Judging by the answers. the emphasis in the Region is on the biological basis of procreation and on subsequent parenthood. The subjects most often given low priority in sex education are pornography and petting. The most controversial subjects- almost equal numbers of respondents claiming them to be unimportant and claiming them to be important- are: the religious view of marriage and the family: petting: masturbation; ster iliza ti on: and sexua l dysfunction. Only one theme. homosexua lit y, is not claimed anywhere to be compulsory in teaching. It seems a reasonable conclusion that the subject of ho mosex ua lity is approached with much more ambiguity than most other subject s. Parenthood, for exa mple, is often considered an important theme and is also often a compulsory theme: presumably, therefo re, it is regarded as something positive. Venereal disease. to take another example. is a lso fair ly often considered an important theme and is not too infrequen tl y compulsory in sex education; it can reasonably be assumed tha t it is regarded as something negative which is better avoided. Attitudes towards homosexuality are often much more 15 Table 3. Numbers of countries answering the question : " Which of the following groups are considered by the government (or other responsible institut ion handl ing these matters, such as the nat ional board of health educat ion or general directorate of health/education) to be important in sex education of young people? Are there any of these themes that are compulsory and part of all curricula and are there any that, on the other hand, are considered not at all su itable for education of young people?" Number of countr ies indicat ing respective importance• Not f it for young Subject 2 3 4 5 Compulsory people Sexual anatomy of humans 1 10 7 Sex roles 2 3 5 4 Parenthood 2 9 5 Reproductive biology 1 10 6 Love 4 5 4 Psychology of puberty 2 3 4 2 Religious view of marriage and the family 4 1 4 2 Pornography 5 2 1 1 1 2 Intercourse 1 1 1 2 5 3 Petting 3 3 1 1 3 1 Masturbat ion 3 1 1 2 3 3 Homosexuality 2 1 3 2 Contraceptives 2 9 4 Venereal diseases 1 3 6 4 Sterilization 2 3 1 3 1 Abortion 2 2 6 1 Sexua l dysfunct ion (e.g. impotence) 2 3 2 3 • 1 = Not important at all 3 = Of some importance 5 = Very important. ambiguous. and compulsory teac hing co rrespondingly more dimcult to in stituti onalize since there is no genera l agreement on how to tackle the issue morall y. This is reg rettable since ind iv iduals with predominantl y or exc lusively homosex ual tendencies ex ist in a ll cultures. and young people during ad o lescence oft en pass th ro ugh a peri od with proc li vities and occasional ac ts that might be ca lled homosex ual. Tha t young people are unlik ely to be in fo rmed about these matters ca n most cert ainl y give ri se to unnecessa ry stra in and anxiety. It 1s also noteworthy that homosex ua lit y is also the only theme not considered ve ry import ant by any respondent. There is only one theme that a t least two co untri es find un fi t fo r 16 young people: pornography. It is. however. interesting to note that . a lthough seven of the nine countries giving a rating to pornography regard it as unimportant and only two countries regard it as important. at least one country regards it as important enough to make it a compul sory theme in sex educa ti on . Which institutions offer sex education to young people? Sex education is provided in countries where it is not compulsory. the institutions that offer it to young people being li sted in Table 4. The tab le shows the number of countries in which institutions offer sex education to you ng people. Table 4 . Numbers of countries answering the question : " Which institutions/organizations offer formal sex education to young people and is the education specially d irected towards young people?'" Institution/ organization Pre -school Primary school Second;:iry school Army Family planning association Student organization Church Women 's movement Other government institutions Other volunti.lry organizations Number of countries Special programme for young people 5 10 14 5 5 7 3 4 5 4 Young people w elcome to join programme primarily intended for adults ( 1 )• ( 1 ) a 4 2 4 4 4 2 •It was stated in the answers. in one case each. that a secondary school and the army organized sex education for adults to which young people were welcome. What is meant by this is not clear since. in most cases. it could be assumed that education arranged by those institutions was primarily meant for young people. None of the instituti ons listed provides sex education in a ll the countries that answered the questionnaire. In 14 out of the 16. secondary schools offer some kind of sex education. but from what has been said above it is clear that there is no guarantee that the ed ucat ion is appropria te in those coun tries. Some initial steps have been taken in those countries. however. and school programmes could be built further on that foundation. As for the other institutions. it might be said that in most coun tries there seem to be a large number of communication cha nnels but that they are not yet utilized . A note of cau tion is 17 appropriate: it may reasonably be assumed that the government agency responsible for answering the questionnaire is aware of the efforts of other government agencies. but it is not quite so certain that it has full knowledge of the activities of voluntary organizations. Family planning for young people The definition of family planning has been discussed above. From the definition quoted it seems clear that family planning is not to be equated with population control, since it consists primarily of services offered and measures taken to enable people to have the number of children th ey choose at the times they choose. The purpose of family planning is thus neither to promote the birth rate when it tends to fall to a level at which the population does not reproduce itself. nor to control a birth rate that is rising so rapidly that it is thought to threaten some perceived optimum population den sity . For WHO, family planning, in accordance with the definition quoted, is seen as a mean s whereby individuals may influence their own health and social condition by deciding on the number of children they want and the spacing between them. This is not to deny the existence of a causal relation between the deci sions made by individuals on how many children they want and the increase or decrease of a population . In by far the most instances birth control is used to avoid rather than to facilitate reproduction. Effective birth control usually means a longer period between births, hence fewer children. The attitude of a government to the birth rate in the country might thus be relevant in studying to what extent family planning services are available. When asked about the position they take in relation to the birth rate in the country. only a limited number of governments, ten in all, chose to answer. Only one country found the birth rate too high. Three countries declared tha t the birth rate was acceptable, five that it was too low . One country ticked two alternative answers: the birth rate is too low, and it is acceptable. In a few in stances, e.g. the United Kingdom . it was pointed out that the government does not take any official view . Yugoslavia remarked that family planning in Yugoslavia is a consti- tutional right , implying that an official attitude to the birth rate would be contrary to such a right. The answers from individual countries appear in Annex 2, together with the answers to other questions intended to elucidate official policy in countries. Distribution and prescription requirements for contraceptives There are three important prerequisites for the successful use of family planning: knowledge , availability, and acceptability . We have earlier discussed the educational efforts of governments in relation to sex 18 education. The formal availability of family planning will be discussed next, but the acceptability of various approaches will be discussed in a later section dealing with the study of selected programmes and projects . One aspect of availability is prescription requirements and other regulations governing the sale of contraceptives. In the questionnaire governments were ased about the availability of various contraceptives to young people . The formal differences between the countries of the Region are minor. In the survey of family planning legislation in seven countries of the Mediterranean mentioned above (4) it was pointed out that the actual availability of contraceptives may be somewhat different from what one is led to believe from the legislation . In some countries prescriptions are required for most contraceptives. but the Pill , in spite of the legal requirements. can usually be bought without a prescription at a pharmacy . Thi s means that differences between countries, at least as far as the Pill is concerned. are greater than the answers to the question seem to imply . Thirteen countries stated that long-term hormone contraceptives are available only when prescribed by doctors. one country that they are not available to young people. and one country that they are not available at all. Oral contraceptives were sa id by 15 countries to be available only when prescribed by doctors. while one country indicated that they were available in pharmacies without prescription . Here a note of caution must be sounded: the practice in many countries seems to be that oral contraceptives are available in pharmacies without prescription in spite of the lega l requirement of a prescription. Intra-uterine devices (IUDs) were stated by 15 countries to be available only when prescribed by doctors. and by one country to be avai lable in pharmacies without prescription. Diaphragms are available in pharmacies without prescrip- tion in eight countries. a prescription is required in seven countries. and the diaphragm is not available at all in one country. Spermicides are available in pharmacies in eight countries without prescription. one country requires a prescription . a nd in one country spermicides are easily available in shops or other public places without a prescription. Condoms are easily available in shops or other public places in eight countries. and in pharmacies only but without a presc ription in eight countries. Major differences in sale regulations concern only diaphragms and condoms. Since the diaphragm needs fitting it is of less importance whether it is available with or without a prescription . It may be of some importance for young people whether condoms are available in shops or only in pharmacies. Since adolescent sexual encounters often seem to be chance and unpremeditated . even the smallest obstacle to availability may be decisive . For th at reason. condoms are in many ways to be preferred as a contraceptive for young people . Facilitating the buying of condoms thus seems to be a very simple way of improving the availability of contraceptives to young people and. given suf- ficient education and acceptability. of increasing the likelihood of the ir use. 19 Target groups for family planning activities Young people arc usuall y considered important target groups fo family planning acti\·itics . Judging from the replies (Table 5) they are. howewr. not the most important group. the group most often seen as an important target group being women with many children. It is interesting to note that young boys and yo ung girls arc seen equally often as important target groups. wherea s the same is not true of women with many children and men with many children. The importance of males must be stressed . Although most contraceptives arc used by females the successful implementation of family planning depends on males accepting and taking part in family planning. The motivation of males is at least as important as the moti\'ation of females. since in many countries men by tradition have a position within soc iety as well as within the couple that makes their acceptance of family planning crucial. It was stated above that the condom is particularly suitab le for young people who do not have a regular sex life. and thi s makes the cooperation of males even more Table 5. Numbers of countries answering the question: " Wh ich of the fellowing groups are considered by the government (or other responsible institution handling these matters, such as the national board of health educat ion or general directorate of health /education) to be important target groups for family planning counselling services?" Target group Women with many children Men with many children Married women Married men All ad ult women All adult men Newly -married women Newly -married men Girls just below usual age of marriage Boys just below usual age of marriage Young girls as soon as possible after menarche Young boys as soon as possible after first emission of semen 20 • 1 = Not important at all 3 = Of some importance 5 = Very important . Number of countries indicating respective importance• 2 1 2 2 2 3 1 1 5 4 5 5 4 3 2 2 4 3 3 2 5 10 7 3 3 5 4 5 6 6 6 8 8 essential among young people . Educating and motiva ting boys to take a respon sible view in these matters would pay ofT a t a la ter date when they enter into more stable relati o nships. A few countries added groups they consider impo rt a nt target groups that are not li sted a mong those in Table 5. These groups are: single mothers (Algeria): abortion patienb and patients with inheritable di seases (Finland): women with a deprived socioecono mic background. rural women. and immigrant women (France). Hungary also commented that in it s opinion all the gro ups are o f equal importa nce : if health for all is the ultimate goal. it is important to mak e family pla nning available to all. T o ma ke it ava il a ble to a ll it might. however. be necessa ry to employ spec ia l tec hniques or make specia l efTorts for some groups. The relative lack of va ri ation in the importance given to the various groups in Table 5 may reflect this conflict between the intended goal (i.e. family pl anning ava ilabl e to a ll ) a nd th e means necessary to ac hieve thi s goal (i .e. se lective a pproac hes) . Legal status of family planning for young people The lega l sta tu s o f fa mil y planning for yo un g people is an ex tremely complicated question. In many. though not all. co untries there is a minimum age below which a patient cannot give hi s or her lega l consent for trea tment. In a few countries such consent is not necessa ry for medica l treat ment. The matter is further complica ted by the fact that in some countri es th ere a re specia l re_gul ations concerni ng public hea lth . To th e ques ti on whether public information on fa mil y planning is lega l o r not. three a lt ern ative a nswers were ofTe red: .. To advertise contraceptives a nd to inform abo ut contraceptives is prohibited by law": .. To advertise to young people and to inform yo ung people about contraceptives is prohibited by law": .. There are a re no lega l obstacles to free informati o n about contraception". One country rep lied tha t it is forbidden to a d ve rti se contraceptives and to g ive information about contraceptives. ano the r tha t it is prohibited by law to advertise to you ng people and to inform yo un g people about contraceptives. Thirteen countries indicated tha t there are no legal obstacles to free information a bout contracep ti on . Th e Un ited Kingdom added the com ment th at branded contraceptives may not be advertised o n televisio n. but that advertisements for officia ll y spo nso red family planning age ncies a re allowed. Yugoslav ia remarked that it is prohibited to advertise contraceptives. but that informa tio n a bo ut co ntracepti ves is welcomed. Both those countries sta ted that the re a re no lega l obs tac les to free information about contracep ti on . There o bvious ly seems to be no obstacle to information although there a re some problem s with the advertising of commercial goods. Min o r regulations of thi s kind probably also exis t in o ther countries. All the countries replied that the sa le and spread of co ntraceptives 2 1 a re in pa rt subject to reg ula tio n , in tha t some cont racepti ves (the Pill and th e IUD) have to be prescribed by medica l p ractiti oners whereas o thers (the condom ) ca n be so ld direc t to the genera l public. No country indica ted th a t the sa le a nd sp rea d of cont raceptives a re illega l in themselves. The ava il a bility of fa m ily pl a nning se rvices to yo ung people is a somewha t mo re compl ica ted ma tt er. N ine countri es indica ted witho ut qua li fica tio n th a t there a re no obstac les to the unlimited use o f fa mil y pl a nning se rvices by yo ung peop le. One co untry (Denma rk ) sa id tha t the re a re no o bstacles but added " lega l if mo re th an 15 yea rs" . Ano th er (Yugos lav ia) sa id witho ut comment tha t there a re no o bstac les to the free use of fa mily pla nnin g but a t the sa me time checked the pre-coded a nswer -- medica l staff offerin g fa m ily plann in g se rvices a re free to assis t yo ung people with cont racepti on but must if the client is a min or ta ke spec ia l steps ( li ke in fo rming the pa rent s o r the client' s usua l phys icia n)". A third cou nt ry (the U nited Kingdom) sa id tha t o nl y under exceptio na l circumsta nces a re cont raceptive serv ices given to pa tients under 16 witho ut pa renta l consent. This seems to mea n tha t even tho ugh pa renta l consent sho uld norma ll y be sought the poss ibility o f p roceeding witho ut pa re nta l conse nt is left o pen ; the a nswer thus indica tes tha t there a re no lega l o bstacles to the unlimited use o f fa mily planning se rvices by yo ung people. Two countries indica ted witho ut qua lifica tio n tha t medica l staff offe ring famil y pla nning se rvices a re free to ass ist yo ung people with cont raception but must, if the client is a mino r, ta ke spec ia l steps (such as in fo rming the pa rents o r the client' s usual phys ician) . Nine countries decla red tha t there a re no lega l obstacles to the unlimited use of fa mily pla nning se rvices by yo ung people. For the countries mentio ned above (Denmark , Yugosla via, a nd the United Kingdo m) the situa tio n is somewha t mo re complica ted . It seems reasonable to conclude tha t there a re no lega l problems even for the very young in the United Kingdom, whereas lega l problems for the very yo ung are likely in Denma rk and Yugoslav ia, a nd poss ibly a lso in a number of o ther countries tha t did not consider it wo rth while to include in their answers deta iled regula ti o ns tha t concern o nl y a frac tio n o f yo ung people. Loca l gove rnment can complica te the issue furth er. The countries indica ting tha t there a re no legal obstacles to the use of famil y pla nning by young people were therefo re as ked if loca l gove rnment s co uld p rohibit fa mil y pla nning centres o r p rogrammes fo r yo ung people even if there was no na tio na l law aga inst it. Only one country sa id th a t it was poss ible fo r loca l gove rnment s to enfo rce such a prohibition ; the United Kingdo m no ted tha t the level of provision was fo r each individua l health a utho rit y to decide, thus implying tha t fa mily planning fo r yo ung people co uld be give n low pri o rit y and hence little fundin g. This is, o f co urse, a possibility in eve ry country. As with sex education , the actua l implementa ti on o f p rogra mmes is usua ll y dependent not onl y on accept a nce by the legisla ture but a lso o n ac ti ve suppo rt by people a t the loca l level. 22 Service providers A decisive factor in availability is that the service providers should be acceptab le to the young. who must trust them. Young people probably in many cases abstain from the use of family planning and related serv ices that are open to them because they fee l. justly or unjustly. that they will be condemned morally or patronized. or that their sexua l activity will be made known to parents or other people in their immediate social surroundings. Table 6 may give the impression that special programmes or clinics for young people exist in a number of countries and are operated by a large number of difTerent institutions. In one respect this is true: in almost all countries specia l programmes or clinics do exist in one form or another. As a rule they are . however. not available nationwide. It must a lso be stressed that the question asked refers to family planning1counselling services. For some countries it is evident that the answer is related primarily to counselling services and not to family planning services. This is particularly important to remember in the light of the claim of seven countries that there are some special programmes for young people organized by schools. programmes that in many cases obviously deal with counselling and not with family planning. The distinction in many countries. however. is not clear-cut. The study visits made it clear that in some cases programmes or clinics exchange clients so that a programme or clinic. which might be operated formally by a school on a personal basis. exchanges clients with another programme or clinic that might be formally operated by some other organization and offer other services . In Warsaw. for instance . there is a school counselling service operated by the school authorities that does not ofTer Table 6. Numbers of countries answ ering the question: " Which institutions/organizations are offering family planning /counselling services and are there any special programmes or clinics for young people? " Institution / organization School Student organization Family planning association Government hospitals Pr ivate hospitals Women's movement Church Other government institutions Oth3r voluntary organizations Number of countries Special programmes or clinics for young people 7 6 7 7 5 3 2 4 3 Young people welcome to programme or clinics primarily for adults 1 6 10 5 5 2 5 2 23 famil y planning services. There is al so a famil y planning programme o pera ted b y th e s tudent o rga ni za ti on. which d oes no t provide any co un selling se rvices. As a result o f pe rsona l cont ac ts between people wo rkin g with these p rog rammes a co:i s tant exchange o f client s takes pl ace. so tha t when schoolchildren go to their co unselling service they can al so recei ve fami ly planning services through the student organi z- a tio n famil y pl a nnin g se rvice . Simila rl y. student s who go to the famil y pl annin g se rvi ce ca n rece ive co unse llin g se rvice fro m th e s ta fT o f the school programme. W o rking a r ra ngement s lik e these a re seld o m fo rm a li7ed a nd o ft en no t within th e o fli c ia l kn owled ge o f th e auth o riti es. Meeting costs Costs may. pa rticul a rl y fo r yo ung people. have a deci sive influence o n the use o r non-use o f fa mil y pl a nning se rvices. There a re two as pec ts to cos ts: firs tl y. the ex tent to which th e government. o r a ny gove rnment in stitutio n . gives eco nomic suppo rt to programmes for sex educa ti o n or fa mil y planning. particul a rly those no t o perating within th e general hea lth sys tem: secondl y. what the c lient has to pay fo r the se rvice. Concerning the fi rst aspect. seven gove rnments indica ted no go\'c rnment suppo rt e ithe r fo r sex ed uca tion o r fo r famil y plan- ning,co un sc lling prog ra mm es fo r yo ung peopl e tha t a re no t gove rnment - o pe rat ed . Eight co untries ind ica ted th a t the gove rnment g ives s ubsid ies. Governments o pera te famil y pl a nning se rvices fo r yo un g people in ma ny co untri es . Eight co untri es sta ted that such se rvices a re ava il a ble in government hospit a ls. five tha t the re a re spec ia l pl anning se rvices th a t ofTcr fami ly plan ni ng to yo ung people. and three tha t there a re o ther gove rnment -operated institut io ns th a t provide fa mil y pl a nning se rvices fo r yo ung people . Fo ur co untri es indicated tha t no such se rvices a re ava il able through the gove rnment. In some countri es these se rvices a re o pe ra ted entirely a t the loca l leve l. so tha t the gove rnment has no direc t a uth o rit y over them . Ten countri es indica ted th a t loca l o r munic ipa l gove rnments o pera te fa mil y pla nn ing se rvices fo r yo un g people. Fo ur countri es indica ted th a t no such se rvices a rc o perat ed by loca l gove rnments. The extent to which famil y pl a nning se rvices fo r yo un g people a re subsidized va ri es fro m o ne country to a no ther . Three countri es indicated tha t famil y pl anning se rvices fo r yo ung people a rc free of cha rge. wh ereas mos t medica l trea tment in those co untri es is no t free of cha rge. Fa mil y pl a nning se rvices a re free of cha rge. as is most medica l trea tment . in nine countries . O ne co untry indica ted tha t famil y plannin g se rvices for yo ung people a re no t free of charge but a re spec.ia ll y subsidized . so tha t the cost is lower tha n fo r mos t medica l trea tment. Fin a ll y. two co untri es indica ted th a t famil y planning e rvices fo r yo ung people cos t the client a bo ut as much as mos t medical consultations. Since yo ung peopl e a re proba bl y mo re cos t-sensitive th an mos t o ther groups, it wo uld be ad visable to subsidize famil y planning se rvices for yo ung people as much as poss ible. In most cases. thi s co uld be seen as 24 an irwcstmrnt 111 the future. since the socia l cost of unwanted pregnancies in early adolescence is high in term s or ruined educa tional pl ans as \.\CII as of the increased medical ri sks of too earl) childbearing. Young people wh o h,l\e learnt early to use family planning properly will he more regular users of famil y planning later in life and thus need less motirntional efforts than those who ha\'e not learnt from the beginning to use family plannin g properl y. Concerning the economic suppo rt the go,-crnment ma y or may not gi,c to programmes or project s that are not operated by it. two point s must also he made . First. in man y countries ,·oluntary organizations such as planned parenthood associations arc totally dependent on go,·crnmcnt subsidies. since they offe r their se rvices to the public in general o r to adolescents in particular at far less th an the actual cost of the sc n ·iccs pro,·idcd . Second. C\'en ,·ery smal l subsidies can have significant effects. symholi1ing a support tha t goes far beyond economic support. In Morocco. for instance. the Family Planning Association receives a small economic support from the Government. With it. howc\'cr. is a recommendation from the responsible minister to all go,·crnmcnt institutiom that they sho uld wherc,·cr poss ible facilitate the action of famil y pl anning associations and share facilities with them if poss ible . The importance of such support is difficult to translate int o mone tary terms. hut it is real. 25 Approaches 3 • selected lil countries The purpose of studying the approaches in selected countries is not to give exhaustive descriptions of the situation in the countries in question. but to describe what is done. for which in many cases it is necessary to discuss the country in question. Comparisons will also be made in some cases between the views of field workers active in the programmes or projects studied and the views of policy-makers. The approaches are sometimes typical of the efforts of the country. in other cases atypical. but in no case does does the approach studied give a complete picture of the efforts in the country. Belgium In Belgium study visits were made to two family planning clinics in Brussels: Aimer Jcunes and Planning Josaphat. Discussions were also held at the Department of Sociology. Katholieke Universiteit. Lcuven. and the Federation beige pour le Planning familial ct !'Education sexuellc (FBPFES). a coordinating organization for many of the various family planning clin ics in French-speaking Belgium. The Federation has clinics a nd centres as members. not individuals. There arc :n such centres associated with the FBPFES in French-speaking Belgium and Brussels. Another 50 centres. of which some only offer advice and do not prescribe contraceptives. are either attached to one of two organizations- the Federation beige des Centres des Consultations conj ugales and the Centre de Promotion conjugale des Femmes prevoyantes socialistes- or function independently. The FBPFES. besides coordinating family planning centres. has two major tasks: as member of the International Planned Parenthood Federation organizing international contacts. and as a liaison office with the French-speaking ministries in Belgium. The latter task is particularly impo rt a nt Ill connexion with the Ministry of Culture. which prefers to make its grants to a central organization that then divides the money between the various local clinics and educational units. The Ministry of Health . on the o ther hand. prefers direct contact with health and family planning clinics and makes its grants direct to the clinics. Besides these main adminis trative tasks. the Federation is also active 27 in the training of educa to rs. a11 ima1eurs, and famil y thera pi sts. T o become a fa mil y thera pi s t recognized by the Fede ratio n fi ve yea rs o f t ra ining are necessa ry. T o become a n anim(lfeur three yea rs o f training a re necessa ry. These training co urses are ma inl y financed by fees pa id by the students. The Fede ratio n is grea tl y conce rned a bo ut these edu- ca ti onal effo rt s since it is m ost unce rt a in if a nd to wha t extent the a uth o riti es will accept dipl omas issued by the Fed e ratio n . The fi rs t st ude nts to have rece ived thi s educa tio n were o ffici a ll y recognized as fa mil y thera pists and educa to rs by the a uth o riti es. but recogniti o n has been o n a n indi vidua l bas is and has no t led to recognitio n of th e training as such . It must be unde rstood , however. tha t m any o f the ac ti vities a re s till in the form a ti ve stage. since fa mil y pla nning ac ti viti es on a la rge sca le a re ra ther recent in Belg ium . Cont race pti ves we re no t legali zed in Be lg ium until 1973 a nd a bo rti on is illega l. The Federatio n has s uffe red greatly fro m th e recent cut s in governme nt budge ts. It is a lso som etimes felt that the Federa tio n is unfa irl y trea ted since the Flemish-speakin g o rga n- iza tions ha ve no t suffered the sa me budget cut s. This is pa rtl y due to the complicated Belgia n sys tem o f gove rning the country: the re a re a lways a t leas t two ministri es for eve ry depa rtm ent. o ne French- spea king. the o ther Flemi sh-spea kin g. a nd o ften al so a spec ia l department fo r Brussel s. which is bilingua l. The minis tries s uffer th e sa me budge t cut s but then the min is ter co nce rned economizes whe re he wishes . the Fl emish-spea kin g minis ter possibl y hav ing o the r prio riti es tha n the French-spea kin g o ne. Pa rt s o f the French-speaking po pula tio n sometimes rega rd the Flem ish-spea kin g popul a tion as co n se rva ti ve and a hindrance to deve lopment. T o them. F lemi sh spea king sometimes seems to be the equi valent o f milit a nt ca tho lic ism . Thi s vi ew is na turall y no t shared by the Flemi sh-spea king Belgia ns. and stereo types of thi s kind a rc usua ll y no t ve ry acc ura te in descri b ing the ac tua l s itua ti on . In spite o f thi s they may. as in thi s ins tance. be evoked as a pa rt o f the soc ia l rea lit y th a t fo rm s the back gro und for peopl e's ac ti o ns. On the wh o le the re has in the pas t. ho wever. been a mo re libe ra l and a nti clerical t rad iti on within W a ll o nia . Th e fi rs t fa mil y pl anning centres were sta rted in the Wa lloon a rea by a group ca ll ed Fa mill c heure use. They were s upported by a gro up o f freemaso ns wh o start ed these ac ti v ities as ea rl y as 1962. Fa mill c hcure use was a lso the fir st group tha t s ta rt ed trainin g co un se ll o rs a nd educa to rs. Aro unJ 1970 a number o f fa mil y pla nning clini cs spra ng up in F rench-spea kin g Belg ium . frequentl y orig ina ting in th e U nive rsitc librc de Bruxelles. which is o ft en perce ived as the radi ca l s tro nghold of sex ua l enli ghtm ent and the champio n o f free a bo rti o n . French-speak ing Be lg ia ns sometimes perce ive the U ni ve rsit y o f Lc uvcn and U ni ve rsi ty of Lo uva in- la -Ne uve to be the s t ro ngho lds of the reac ti ona ry fo rces in th e co untry. T hi s is na tura ll y al so a view no t sha red by F lemi sh-spea kin g Belgians. In rece nt yea rs. howeve r. ma ny o f the traditi ona l d ifTe rcnccs have dim ini shed . The birth ra te nowadays is a lmost the same in the di ffe rent p rov inces. In trying to unde rs ta nd fam ily pla nning ac ti viti es in Be lg ium it 1s 28 useful to compare them with those in another country. taking the special bilingual situation of Belgium into account. In relation to the Netherlands (see p. 58) it was pointed out that an entrepreneurial system existed, voluntary organizations being responsible for carrying out a number of fami ly planning activities that were totally, or almost totally, financed by the Government. This system is also common practice in Flemish-speaking Belgium, where confidence in the State has traditionally been limited because earlier it was dominated by French-speaking people. This "Dutch" system is not as firmly rooted in French culture . The whole of Belgium seems. however. to utilize it for family planning. the Government paying for family planning services by reimbursing the clien ts and. at least to some extent. supporting the clinics financially . This 1s a simple way of avoiding dealing with the politicall y inflammatory question of family planning and abortion . One important difference between French-Speaking and Flemish- speaking Belgium must be noted in connexion with sex eduation . In the French-speaking parts of Belgium special educators who have been trained at the Federation beige pour le Planning familial and arc attached to some family planning centre are important transmitters of sex education. since they often visit schools and youth clubs. In the F lemish-speaking part of Belgium such animateurs do not exist: to the extent that sex education is given to Flemish-speaking children it is given by schoolteachers .. Aimer Jeunes, Brussels Aimer Jeunes is a small group of people who. with much idealism and enthusiasm and little money. work on sex education and family planning for young people aged 15- 20 years . The planning centre is in central Brussels. its facilities old and very simple. The group is associated with the Federation beige pour le Planning familial et !'Education sexuelle. which is the national family planning association and the IPPF member for the French-speaking part of Belgium. The Federation is an organization for cooperation and for exerting political pressure. each family planning agency having to finance itself. This is the main problem for Aimer Jeunes . The activities of the group can be traced back to an initiative of students of the Univcrsite libre de Bruxelles. The activities then gradually developed so that the group now offers family planning to young people in general, which led to the loss of financial support from the university. At present the activities are financed by fees from clients and contributions from the social insurance system. which pays the group for each adolescent client treated . Additional grants are available sporadically from the Government. Since the grant from the universit y disappeared the economy of the country has changed from bad to worse. so that no one working with the project can count on a regular salary . Those active in the group work 2- 10 hours a week and are paid when money is available . "Salaries" are differentiated. although the difference in "salaries" is smaller than is usual in Belgium . 29 The clinic is o pen eve ry a ft e rnoon fo r co unse lling and every evening for medica l ass istance. which usua ll y means cont race pti ve advice and trea tment of genit a l infec ti o ns. Acco rding to th e gro up. thi s famil y pla nning clinic is the o nl y o ne o f it s kind in F rench-spea king Belg ium gea red spec ia ll y to yo ung people. In spite of the lack of fund s and of the poss ibilit y of pla nning fo r the future. the gro up ma naged to g ive sex educa tion during 1980 to a bo ut 7000 yo ung people. ma inly in schools a nd yo uth clubs. About 1000 girl s received help with contracepti on a nd 100 boys and 400 girl s medi ca l trea tment fo r sexuall y rela ted problems such as infectio ns. Fifty girl s and 50 boys a lso utilized the o ppo rtunit y of hav ing pe rsona l co un se lling. So me 300 gi rl s a nd 300 boys a lso te lepho ned Aimer Jeunes to seek a nswers to q ues ti o ns. The yo ung peo ple wh o run Aim er Jeun es say th a t if they had fo reseen all the p ro blems and o bstac les they have encounte red they wo uld no t have left the un ive rsit y to wo rk o n famil y pl anning a t Aimer Jeunes. CharaC/er and financing of proy ra111111e Famil y pl a nning a nd coun sell ing a re seen as the prima ry tasks fo r the project. a lth o ugh it a lso d ea ls with sex educa ti on. Th e p rojec t is conside red to be pe rma nent a nd will cont inue as lo ng as fund s a re ava il abl e. The p rogra mme is assoc ia ted with the Federa ti on beige po ur le Pla nning fa mili a l e t l'Educatio n sexuell e. There seems to be no o t'he r programme within th e fede ration so lely fo r yo ung people . The fede rati on is o rga nized ra the r loose ly a nd is quit e different fr o m. fo r insta nce. the Rut ge rs Stichting in the N ethe rl a nds. wh ich has considerabl e influence ove r the fa mil y pla nnin g clinics a nd opera tes them itse lf. The objec ti ves o f Aimer J eunes have been dec ided by the gro up it se lf a nd no t by a ny o the r o rga ni za tio n . Of th e cos t. 40 °., is covered by gra nts from ministri es . 10 'J., by grant s fr om voluntary o rgani zatio ns. an o the r 10 °., by fees pa id by the client s. Fo r the educa ti ona l programm es specia l fund s have been available fro m the G ove rnment a nd am o unt to 20 °., o f the to ta l cos ts o f the programme. The soc ia l in surance sys tem a lso contributes 20 °., o f to ta l cos ts by re imbursing the projec t fo r se rvices fa lling within the natio na l hea lth sys tem give n to yo un g people who a re no t themse lves contributo rs to soc ia l insura nce b ut a re a ble to benefi t fr om it through the contributi o ns o f the ir pa rent s. This d escripti o n o f ho w the p rogra mme is fin a nced is subject to a number o f complicating fac to rs. s ince it s fundin g is uncerta in and the funding so urces vary fro m time to time. Personnel Owing to th e unce rt a in funding. o nl y eight persons a re wo rking with the c linic: ea rlie r. 14 people were a t least pa rti a ll y empl oyed . The present s ta ff co nsis t o f fo ur ph ys icia ns. o f wh o m o ne is a gy naeco logist (ma le) 30 and three general practitioners (two females and one male), two female socia l workers, and two educators (one male and one female). There is no job rotation, the staff having clear-cut areas of responsibility. Those who work at present with the project have been recruited by self-se lection, and new staff would be recruited m the same way. Targ et groups and characteristics of clients The target group is usually described as young people. A bout 80 ° 0 of those attending the clinic belong to the group of young people up to 20 yea rs of age. They could equally well have gone tu other family planning c!inics, which basically offer the same services. The reason why they go to Aimer Jeunes is believed to be that the centre has a special interest in and experience of young people and their problems . Aimer Jeunes also makes a point of not moralizing about the sexual behaviour of its clients. It is believed that the majority of the clients have had at least some kind of sex education before their contact with Aimer Jeunes. Publici::ing the programme The methods used to make Aimer Jeunes known are posters in schools and youth clubs. personal contacts with youth clubs. and personal approaches to schools. The most important method . hnwever. is recommendations by former clients to friends. The group has had serious problems in publicizing it s se rvices . The main obstacles have been lack of money and lack of cooperation from other institutions. mainly youth information centres which , according to Aimer Jeunes. do not inform young people often enough about the existe nce of Aimer Jeunes . The group also think s that its access to schools is too limited, owing to what is perceived as the uncooperative- ness of school leaders. who are afraid of having sex education taught and the services of Aimer Jeunes made known in schools . Obstacles Among the possible obstacles li sted (Table 7). four were seen as serious problems: traditional values in society. the permanent ri sk of being forced to close from lack of money or of political support. and the lack of continued training for the personnel. Other important. but less pressing. problems are the objections of parents to fami ly planning for young people : the uncooperative attitude of boy friends : refusal by society to recognize that young people have intercourse: and lack of equipment. It is interesting to note that. according to the group. no particular obstacles were anticipated when the clinic opened in 1975 . Possible themes and targets Of all the possible themes for sex education discussed. only four were not seen as being important or very important. The sexual ana tomy of human beings and pornograph y were seen to be of some importance only and parenthood and the religious view of marriage and the family as not being important at all. 31 Table 7. Aimer Jeunes, Brussels: rating of possible obstacles Possible obstacle Potential clients have too vague an idea about family planning Potential clients are hostile to family planning Potential clients are hostile to sex education Parents of potential c lients object to family planning for young people Parents of potential clients object to sex education for young people General traditional values in society I I literacy The uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme/ project centre makes it difficu It to reach Business hours of the programme/ project make it difficult for potenti al clients to get in touch Other organizations / institutions do not tell potential clients about project Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of poli - tical support Lack of specialist personnel Lack of voluntary workers Lack of continued training of personnel Problems of cooperation among staff Lack of clearly understood objective Lack of clearly defined target group Lack of equipment • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem Indication of importance• 3 1 1 4 3 5 3 4 4 2 5 5 1 1 5 2 2 1 4 Concerning target groups for sex education and family planning. the centre does not discriminate between services and education. All the groups discussed were regarded as equally important. Number of" clients. serrices . and fees In the past year. some 3500 boys and 3500 girls received sex education through the efforts of Aimer Jeunes in schools and youth clubs . Contraceptive services were given to I 000 girl s and other gynaecological or medical services to I 00 boys and 400 girls. Counselling was given to 50 boys and 50 girls. and telephone advice to 300 boys and 300 girls. Two percent of those who received contraceptive services were 32 ad vised to use cond oms. Ano ther 2 " .. were ad\' ised to use spermicides. and di aph ragms wen: fi tt ed to I "., . IUDs we re inse rt ed in 15 °., o f th ose who received cont raceptive se rvices: ora l cont racepti ves were prescribed fo r the remain ing 80 °,,. The fees pa id by th e cli ents \'a ry accordi ng to th e se rvice given . Co ntracepti ve ad\'ice lead ing to a prescript ion cos ts B.fr . 100 . A pregnancy test is carr ied o ut for B.fr. 50. In sertion of IUDs cos ts the cli ent B.fr . 420. T rea tm en t of ge nita l in fec tio ns costs B.fr. 100. Ai mer Jeunes is open for information a nd coun se ll ing between 12.00 and 14.00 o n weekdays . Medica l co nsul tations are arni lable betwee n 17.00 a nd 19.00 on weekdays and a lso from 12.00 to 19.00 on Wednesdays. C lients usuall y phone in ad\'ance to make an appointment and ca n usua ll y be see n o n the same day . When a clie nt co mes for co ntracepti ve ad vice or for a genital infec tio n he or she is fi rs t g1\'en in fo rm a tion on co nt racepti\'cs. th e \'a ri ous con tracepti \'e met hods being di sc ussed. A gy naecologica l exa mina tion and or prescr ipti on of a contrace pti ve fo ll ow. The firs t check-up takes pl ace three month s la ter. with subsequent check-ups every six months. Planning Josaphat, Brussels Pl anning Josa pha t is a hea lth and fa mily pl ann ing cen tre run by 11 wo men. none full -t ime. There is. however. a fe ma le psychologist who is a full -time wo rker a t the centre. She is pa id by the Mini stry of Labour as part of an unempl oy ment sc heme. The centre a lso util izes fi ve vo lunteers who arc a lso client s. The serv ices offered incl ude co un se lling. medica l co nsulta tions. famil y planning se rvices. lega l help. ph ys iothera py. famil y thera py. and educa tiona l gro ups. Planning Josa pha t bega n in 1975 when three genera l practitio ners (two men a nd a woman) and a nurse opened a hea lth and famil y pl anning centre at Rue Josa phat. in an a rea inh abit ed ma inly by low- status low-inco me gro ups. Sevent y percent of the popul a tion in th e a rea a re immi grants. predomina ntl y Morocca ns and Turks. Morocca n immigra tion beca me significa nt in the mid - I 960s and now th ere is a generation of teenagers bo rn in Belgium of Morocca n pa rent s. Thi s group is pa rticul a rl y vulnera ble since it is sa ndw iched be tween two ve ry different cultures. The cent re offers specia l se rvices to these yo un gs ters and has on it s staff a Morocca n woman psychologist. Two ma le phys icians who o ri gin a ll y pa rticipa ted in se tt ing up the centre left it later. on the gounds tha t the cent re had decided to pay eve ryone the same a mount fo r each hour devo ted to the centre. It was fe lt among the wo men who were left tha t wo rking among immigra nts. and part ic ula rl y among im migran t wo men. wo ul d be considera bl y easier if the entire staff was fema le. This since then has been the policy of the centre. Abo ut half of th e clie nts are im migra nt s and abo ut half French- spea king Belgians. Clients who are able to pay a fee are req ues ted to do so . Since th e na ti onal hea lth se rvice in Belgi um covers a lm os t the entire 33 po pula tio n, most of wha t is pa id to the hea lth centre is reimbursed by th e na tio na l hea lth serv ice. Some groups. howeve r. rema in o ut side the hea lth se rvice sys tem . Temporary visito rs who have no t registered as immigrant s a re no t covered. Yo ung people are covered th ro ugh th eir pa rent s. but to o bta in re imbursement they need the health insura nce ca rd of their pa rents. which they sometimes prefe r no t to ask fo r. Those wh o have difficult y in pay ing a fee do not have to pay . Th e cen t re o rga nizes educa ti o na l groups on th e fo llo wing th emes: hea lth educa t ion : sex educa tio n: in fo rma tio n o n cont race pti ves. a bo rtion. pregna ncy. a nd delivery: emo ti ona l li fe; a nd rela ti o ns be tween pa rent s and children . In the pas t yea r spec ia l educa tio na l gro ups have al so been a rranged fo r yo ung imm igra nt girl s. under the titl e o f language lessons. This educa ti onal programme enco urages pa rents to send their yo ung da ughters to the ce ntre. where th ey a re ta ught the la nguage but al so info rmed a bo ut the o ther se rvices avai lab le a t the centre . Th e centre is loca ted a t present in a n old ho use with a wa iting-roo m and a sma ll examination room on the ground fl oor, and a bigger room used for offi ce work . therapy a nd counselling on the first floor . The centre pla ns to move to o ther mo re suit a ble premises onl y a few blocks away within the nea r future. Th e centre is o pen da il y fro m 09.30 to 12.00 and 13.00 to 17. 00 fo r coun selling. Medica l consult a tio ns. i.e. contracepti ve se rvices and treatment o f genita l infec tio ns. a re given o n Tuesday, Wednesday and Thursda y a ft ernoons. Lega l advice is ava il able fo r o ne ho ur a week and phys io th era py three times a day . Educa tiona l gro ups are held fo r three ho urs da il y. Famil y the ra py is ava il a ble fo r two ho urs a week. Spec ial d iscu ss io n gro ups for immigra nts a rc held o n F ridays and Sa turdays. Almos t eve ryo ne wo rkin g a t the centre is a lso a priva te practitio ner and can be reached during the res t o f th e week a t her priva te prac tice. Th ere the patients have to pay the usual fees . At the centre the fees are. as noted above. negotiable. The limited income o f the centre a nd the multitude of services offered mea n tha t wages a re ve ry low. Th ose who wo rk with the centre receive B.fr . 300 an ho ur . The most striking fea ture o f the centre is the combina ti on o f a high p ro fess iona l leve l and a non-a utho rita ri a n structure. The women wo rking with the cent re take pride in being self-suppo rting profess io na l expert s. The low-k eyed a nd no n-a utho rit a ri an a tmosphere is a result of p ro fess iona ls acknowledging the p ro fess io nal capacit y o f each other. Charac /er and financing of' prog ramme Neither fa mil y pla nnin g no r the sex educa tion of yo ung people is the prim a ry purpose of the centre. a ltho ugh it prov ides bo th fo r yo ung people. The centre is perma nent a nd will continue it s acti vities as lo ng as is poss ible. The centre is assoc ia ted with the Federa tion beige po ur le Planning fa milia l et !' Educa tio n sex uell e. Funds a re. howeve r. no t ava il a ble from the Federa ti on. which is o nl y a coo rdina ting o rga niza tio n. In 1980 th e 34 to tal cos t of the centre was B.fr . 1.6 m illi o n . In 198 1 cos ts will ri se owi ng to th e spec ial p rogra mme fo r immigra nt ad o lescent s. Th e increase will consist o f th e sa lary fo r o ne perso n a nd ex penses. in a ll B.fr . 660 000. In 1980. 48 °,. of th e cos ts we re CO\'cred by th e Min is tere d e l"Empl o i et du Tra va il. a no the r 30 ° ,. by the Mini stere de la Communa ute fr a rn;ai se d e la Santc publiq ue. 2 ° ,. by th e munic ipa lit y. and th e rema ining 20 ° ,. by fees fr om the c lient s. As has been menti o ned . mos t of th ose fees a rc rei mbursable th ro ugh th e na tio nal hea lth sys tem . Personnel The centre d epends fo r it s ac ti vit ies on the coopera ti on o f vo luntee r wo rke rs. This is pa rti cul a rl y true fo r the wo rk amo ng im m igrant s. where fi ve wo men wh o a lso a re cli ent s a re used to spread kn owledge a bout th e centre. Those empl oyed a t present arc two soc ia l wo rk ers. o ne ass ista nt soc ial wo rk e r. o ne ph ys io thera pi st. o ne mid wife . two lawye rs. one famil y therapi st. one psychologist. one genera l practitio ner. and one gynaecologist. Th ere is a s ta ff mee tin g o nce a week a t which the tasks a re a ll oca ted . Staff members o ft en ma ke ho me visi ts and these a re decided upo n a t the mee ting. The staff is rec ruit ed thro ugh self- se lec ti on. th ose initia tin g th e programme se lec ting th ose empl oyed la te r. Tary er yroup.,· and chm·acll' ris rics o( clients There is no specia l ta rget group: eve ryo ne in need is welcome a t the centre. There is. however. a specia l p rogramme fo r adolescent immigrant s. the ta rge t g ro up here be ing usua ll y defi ned as immigra nt girls aged 14- 26. In the di strict there a re abo ut 100 000 women. 50 ° 0 o f whom a re immigrant s. about ha lf Mo roccan and about ha lf Turkish. The client s co uld . a t leas t in principle. go to o the r hea lth a nd famil y pla nning centres o r priva te p rac titio ne rs to rece ive the same medica l se rvices. The reasons th ey go to thi s centre a re ma ny. The se rvices a re comprehensive. ra nging fr om ph ys io thera py a nd relaxa tio n to fam ily therapy. legal ad vice a nd medica l trea tment. The centre is a lso. through it s ac ti vities. well kno wn in the surro unding di stri ct. It is impo rt ant for wo rk with the immi gra nt s th a t th e staff is entirely fema le; since the cultures from which the immigra nts usua ll y come a re more pa tri a rcha l th an in Belg ium . immigra nt s a re sometimes reluctant to a llow their wi ves a nd d a ughte rs to go to Belg ia n institutio ns. Their relucta nce is grea tl y reduced when th ey ca n be ass ured th a t their wives and d a ughte rs will be seen by women o nl y. At the cent re the sta ff a lso try to take mo re time with their client s a nd expl a in medica l trea tm ent in grea te r deta il th an is usua l. It is the po li cy o f the centre to have two wo men present during gynaeco logica l examina tio ns. The centre a lso a rranges fo r straight fo r- wa rd deli veries in hospita ls. It is believed th a t the immigrant client s have not usually received a ny sex educa tio n befo re their initi a l contac t with the hea lth centre. It is believed that some, but less tha n the majority. o f the Belgia n clients have had some type of sex educa tio n . 35 Puhlici:iny thl' prowamme The most important factor in making the programme known to potential clients is the close contact the staff have with their clients. Clients then usually recommend the centre to their friends. Five female volunt ary workers are also used. each working half a day once a week making contacts with potential clients. The main obstacles to making the programme known have been lack of money and limited access to some target groups. Lack of money has made it almost impossible to use costly methods such as posters and brochures. That there is limited access to some target groups is mainly because immigrant parents are reluctant to let their daughters use the services offered by the centre. A special programme 1s. however. being newly implemented and a Moroccan woman psychologist has been employed. Ohs tac/es The important obstacles are: that potential clients are hostile to sex education: that parent s of potential cli ents object to family planning for young people: that parents of potential clients object to sex education for young people: and that it is not socially recognized that young people have intercourse . As can be seen from Table 8. the persistent economic recession is not seen as a serious threat to the health centre. In spite of economic difliculties there is great confidence in the clinic's potentialities. as 1s shown by the proposed acquisition of new premises. Possihle themes and wryets Only three of the possible themes for sex education were not con- sidered important or very important: the religious view of mar- riage and the family. homosexuality . and sterilization. With special reference to the sex education intended for immigrants. one theme considered important that has been added to the original list is virginity and its social implications . In rating the importance of possible target groups for sex education and family planning the feminist character of the centre becomes evident: in no instance has a male group been rated to be even of some importance as a target for sex education or family planning. whereas females arc always seen to be of at least some importance. NumhN of clients. serrices yiren. and .fi'es Because of the spec ial efforts for Moroccan adolescents they are kept separate in the statistics. The numbers of adolescent non-Moroccans were: 150 girls and 20 boys who received sex education at the centre: 300 girls and 100 boys who were given contraceptive advice: 100 girls and 5 boys who received medical treatment other than contraceptives: and. finally. 50 girls who took part in therapy. The immigrant programme concerns girls almost exclusively: in all not more than 20 boys were seen in connexion with sex education. Sex education was. however. given to not less than 350 girls. contraceptive services to I 50. 36 Table 8 . Planning Josaphat, Brussels: rating of possible obstacles. Possible obstacle Indication of importance• Potential clients have too vague an idea about family planning Potential clients are hostile to family planning 3 2 Potential clients are hostile to sex education 4 Parents of potential clients object to family planning for young people 4 Parents of potential clients object to sex education for young people 4 General traditional values in society 3 Illiteracy 2 The uncooperative attitude of boy friends 3 That it is not socially recognized that young people have intercourse 5 The geographical location of the programme/project centre makes it difficult to reach Business hours of the programme/project make it diffi cult for potential clients to get in touch Other organizations/ institutions do not tell potential clients about project 3 Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of political support Lack of specialist personnel Lack of voluntary workers Lack of continued training of personnel Probl ems of cooperation among staff Lack of clearly understood objective Lack of clearly defined target group Lack of equipment •1 = No problem wh atsoever 3 = Some problem 5 = Severe problem 1 3 2 2 2 2 o ther medical se rvices to 50, a nd various forms of therapy to some 20. The mos t often used contraceptive at the centre is the Pill: of those who recei ved contraceptive se rvices 63 ° 0 were prescribed the Pill. Thirty percent received IUDs and 5 °0 were fitted with diaphragms. Another 2 °0 were given long-actin g injectable contraceptives. 37 The centre is open on weekdays from 09.30 to 12 .00 and from 13 .00 to 17 .00 for appointments and guidance. Medical consultations. including contraceptive advice. are given on Tuesdays between 16.00 and 19.00 , on Wednesdays between 13 .00 and 16.00. and on Thursdays between 13.00 and 18 .00. Legal advice is available on Tuesdays between 18.00 and 19.00. Relaxation and physiotherapy are available three hours each day. Marital counselling is available for two hours a week and health education groups are held for three hours daily . There are also special discussion groups for immigrants on Fridays and Saturdays between 14.00 and 18.00. Consultations are available on appointment as well as without appointment. When the client first calls in order to make an appointment a time is usually fixed for the same day or at least the same week . The client is then met by one of the staff members . who has an introductory talk with the client. explaining how the centre work s and which health services are available. The staff member then takes the client to the relevant service provider. The service most often asked for is contraceptive advice. As has been mentioned, the fee the client has to pay is negotiable. depending on whether the client can claim reimbursement from the national health insurance or not. Federal Republic of Germany In the Federal Republic of Germany visits were made to the main oflice of the German Planned Parenthood Federation (Pro Familia Bundesverband) and to one of their local service centres (Pro Familia Beratungsstelle. Bornheim). Pro Familia is almost entirely dependent on government money and is incorporated into the welfare system of the country through an association of voluntary welfare agencies that is recognized by the Government as constituting an integral part of the Federal Republic welfare system. The local organizations of Pro Familia (handesverbiinde) have volunt:uy members who elect local councils. which in turn elect the council of the Federation . The system could be called entrepreneurial and resembles that of the Netherlands. A tendency towards the same system was also observed in the Flemish-speaking parts of Belgium; the system there is. however. controversial and rather alien to the French-speaking Belgians. There are also important differences between Pro Familia and the Dutch Rutgers Stichting, which is a private concern with no voluntary members . In having voluntary members and in being dependent for its general policy on councils elected by voluntary members , the Pro Familia much more resembles the Dutch organization and the NYSH which, however, is not government funded . This peculiar mixture of voluntary organization and government welfare agency is typical of the situation in the Federal Republic of Germany. 38 Pro Familia Bundesverband Character ol programme and financing The primary task of the Federation is to coordinate activities, facilitate international cooperation, keep statistical records, be responsible for the training of the stafT, facilitate a nd promote public relations, and maintain a library. Since the country is a federal republic. a coordination agency like the Bundesverband is almost essential. Through the Bundesverband numerous evaluations have been undertaken and often published. Probably no other family planning associa tion conducts and publishes studies to the same extent. The quality and usefulness of the research varies. Often the evaluations are carried out by students as part of their examination at a university ; some times the academic aspirations of the student and the classroom character of the paper are somewhat too apparent. With the help of these students Pro Familia has, however. a much better knowledge of the results of its efforts than most other service-providing organizations. The Federation is a member of Spitzenverband der Freien Wohlfahrtspftege. an association of voluntary welfare agencies to which government funds are a llocated. The general policy of the Federation is decided by a council. Its members are unpaid volunteers. In 1981 the budget of the Bundesverband was about OM I million; that of the entire organ ization. including service-providing clinics, was OM 13 - 14 million. The expenses of the Bundesverband were 95 ° 0 covered by government money, the remaining 5 °0 being covered by the local organizations and private donations. About 80 ';;, of the expenses of the service-providing clinics were covered by local government or federal funds. The rest was covered by fees paid by clients, membership fees. and other funds that the local organizations cou ld raise. Federal funding is available only during the initial phases of new projects. Personnel At the office of the Bundesverband seven persons are employed full-time, and two men who are conscientious objectors to military service work with the organization as an alternative to military service. The manager. a woman, is responsible for the administration and for international contacts and contacts with scientific organizations. A man is responsible for project coordination, documentation. and contacts with other organizations in the country . A woman is responsible for the training of the stafT and contacts with medical organizations. Another is responsible for public relations and information . A man is responsible for finance and personnel. Finally. there are two female secretaries. People have clear-cut areas of responsibility and there is no job rotation. People are appointed after public advertisement of vacancies and se lecti on among candidates by a recruitment committee . The final decision rests with the manager. The same procedure would be utilized for new vacancies. 39 Ta ryet yroups a11d characteristics of' c/ie11ts Witho ut excl ud ing ot her groups. the Federa tio n ta kes a spec ia l inte res t in yo ung people. immi gra nts. milit a ry personnel. a nd wo men with abo rtio n problems. By yo ung peo ple is usua ll y mea nt people in the age bracket 13- 2 1 yea rs. Abo ut 40 ° 0 of the client s belo ng to th ose groups. The interest in spec ia l ta rge t groups deve loped gradua lly. Origin a ll y se rvices were prov ided wi tho ut a ny effor t to reac h any pa rticul a r gro up. In I 974. howeve r. spec ia l effo rt s we re made to fac ilita te con tacts with yo ung people. Immigra nts we re adcied as a specia l ta rge t group in 1978 and milit a ry pe rsonnel in 1979 . The spec ial inte res t ta ken in women with a bortion p robl ems is a res ult o f th e legislat ion o n a bo rti on : acco rding to tha t legisla ti on a woman who a pplies fo r a n abo rti on has to pa rticipa te in a co unse lling session a t which her pos iti on a nd dec isions a re di scussed . Pro Famil ia is recognized by the G ove rnment as a n age ncy th a t provid es such coun selling. which is pa id fo r by th e G ove rnment. Immigrants fo rm a n impo rta nt group a mo ng the client s. In 1975 about 7 °0 o f the clients were immigra nts. in 1979 16 ° .,. Alm os t half of the immigra nts a re Turkish . In principle. client s co uld go e lsewhere fo r contracepti ve advice. In the Federal Republic of G erma ny there a re seve ra l sma ll o rga nizatio ns tha t o fTer a bo rtion ad vice and contraceptive se rvices . N o o th er o rganiza tio n ofTe rs. howeve r. the sa me ra nge of se rvices as P ro Fa mil ia: sex educa ti on. co un se lling. thera py. and cont racepti ve se rvices. The majo rit y of the client s a re believed to have had prev io us sex ed uca tion . a lth o ugh its q ua lit y is co nsidered to be varia ble. Puh/ici:: iny the proyran,n,e At the office of the Bundesverba nd there is a public rela ti o ns o ffice r wh o is in perma nent contac t with the press. Numerous brochures a nd leaflets a re produced . Some in fo rm a tio n ma te ria l is a lso published in foreign la nguages and sometimes has a n impac t in o ther co untri es. as in Po rtuga l. Th e Bundesve rba nd a lso info rms soc ia l workers a nd ph ys ic ia ns a bo ut the se rvices ofTe red so tha t client s ca n be refe rred to it. The mos t importa nt mode of rec ruitment of new c li ent s is through phys ic ia ns referring the ir pa tients to P ro Fa milia: abo ut ha lf o f the c lient s a re believed to co me to the o rga niza tio n a ft e r ha ving been to ld a bo ut it by their physic ia n. G enera l prac titio ners in the Federal Republic of G erm any dea l with fa mil y pl anning to a much lesse r extent tha n in mos t o ther countri es. One reason fo r thi s is tha t leg isla tio n in the Federa l Republ ic o f G erma ny fo rbids general prac titi o ners fro m inse rting IU D s: o nl y gynaeco logists a re a llowed to ma ke such inse rti o ns. The Bundesverba nd has no t enco untered a ny pa rticul a r obstacles in trying to ma ke it s se rvices known to po tent ia l use rs. Ohs tac/es Onl y one of the po tentia l o bstacles di scussed was see n as co nstituting mo re tha n a min o r problem : the lack of specia li st pe rsonn el was fe lt to be an importa nt. a lth o ugh no t a se rio us. p ro blem. An additiona l 40 problem was menti o ned. the mixture of a vo lunta ry o rga niza tion and a profess iona l one. as when the respo nsi ble positi o ns a t the local leve l are to be filled by volunteers . Recruiting competent members is sometimes difficult and. since their professio nal interests may lie elsewhere. they often have insufficient time for Pro Familia . Sometimes coordina tion of the basically independent loca l o rga nizat io ns creates problem s. Possihle rhemes and targe ts Children at secondary school were rated as a n importa nt target group for sex ed ucation. Ad o lesce nt girls. adolescent boys. girls just below the usual age of marriage . a nd boys just below the usua l age of marriage were rated as ve ry important targets . All of th ose groups were also included in th e targe t of Pro Familia. Other groups were considered less impo rtant. As rega rds rating the importance of reaching various groups with family planning services. it was po inted o ut tha t. accord ing to the official pol icy o f Pro Fam ilia. a ll groups are equa ll y important. In reality special emphasis is placed o n yo ung people irrespective of their marital status. Numher ol clients. se1Tices gil'l'n, and f ees No services a re offe red by the Bundesverband directly to clients . The Bundesve rba nd is responsible for coordi nation between the serv ice- providing agencies. Pro Familia Beratungsstelle , Bornheim The Pro Familia Beratungsstelle . Bornheim. is located in Frankfurt. where th ere are four se rvice-providing cli nics belonging to the Pro Familia organization. Two of them a re very small and open only during a few hou rs a week . The clinic in the Bornheim district 1s. by Pro Familia standards. medium-sized. There is another Pro Familia clinic in Frankfurt that is cons iderab ly bigger. Character and financiny of programme Since the cli nic is open to a ll age groups. neither family planning nor the sex education of young people is its primary purpose. Sex educa tion and family planning counselling services are. however. offered to young people a lso. The clinic is perma nent a nd will continue its operations as lo ng as funds a rc available. Since it is attached to the Pro Fam ilia organization it co uld be said that its objectives are se t by the Bundesverband. The policy guidelines of the Bundesverba nd a re. however. so genera l that the ac tua l policy of the clin ic is decided upon by those who work there . In 198 1 clinic costs were OM 60 000. 42 ° 0 met by the Federal Government (mainly fo r counselling in re la tio n to abortion requests). 40 '1/,, by loca l governmen t. and 10 ° 0 by the fees of clients . An additional 6 °0 were met by fees for services to hospita ls and the remaining 2 °0 by private donations. 41 Personnel Everyone working with the programme is paid for his or her services; no voluntary workers are used in any capacity. At present eight persons are employed, the only one working full-time being a male sex educator who is. however, paid not by Pro Familia but by the Ministry of Labour as part of an unemployment scheme. The remaining stafT are all female and consist of a social worker. at present working 25 hours a week, a medical general practitioner working six hours a week, a nurse who also works six hours a week, a sex educator working 20 hours a week, two counsellors each working three hours a week, and a cleaning woman working four hours a week. People have clear-cut areas of responsibility and there is no job rotation. The stafT in theory has been selected by public advertisement of vacant positions and selection among candidates by a recruitment committee. In practice the stafT is self-selected. Since the system has worked satisfactorily there would be no changes if additional people were employed . Target groups and characteristics of clients Groups in which the clinic takes special interest are young people aged 13- 21 and women seeking an abortion. About 90° 0 of the clients are believed to belong to those two groups. The present target was adopted in 1978 when changes in the legislation made abortion available but preliminary special counselling mandatory. The clients could go elsewhere to obtain the services ofTered at the clinic. either to other Pro Familia clinics or to other organization~ that also ofTer family planning. At the clinic it is believed that the clients go to them because Pro Familia is known for having an accurate knowledge of a variety of contraceptives. The neighbourhood image of the clinic also counts: the vast majority of the clients come from the district where the clinic is located . It is believed that the majority of the clients have had previous sex education at school. Puhlici::iny the proyramme The clinic advertises its existence in local newspapers . It also tries to make itself known by contacting local schools and local physicians . It is believed. however. that the most important wa y of recruiting new clients is through the recommendations by those who already are clients . Those working at the clinic do not think there has been any substantial problem in making the clinic known to potential users . Ohs tac/es As can be seen from Table 9. none of the obstacles discussed is perceived as a serious problem. but five are considered to be problems : potential clients have too vague an idea about family planning: potential clients are hostile to sex education: parents of potential clients object to family planning for young people: people are illiterate: boy friends are 42 Table 9. Pro Familia Beratungsstelle, Bornheim: rating of possible obstacles Possible obstacle Potential clients have too vague an idea about family planning Potential clients are hostile to family planning Potential clients are hostile to sex education Parents of potential clients object to family planning for young people Parents of potential clients obiect to sex education for young people General traditional values in society Illiteracy Th e uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme/proiect centre makes it difficult to reach Business hours of the programme/proiect make it difficult for potential clients to get in touch Other organizations/ institutions do not tell potential clients about project Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of political support Lack of specialist personnel Lack of voluntary workers Lack of continued training of personnel Problems of cooperation among staff Lack of clearly understood objective Lack of clear defined target group Lack of equipment • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem Indication of importance • 4 3 4 4 3 3 4 4 3 2 1 3 3 3 1 1 1 1 uncooperative. Here it must be pointed out that a substantial part of the clients at this clinic. as at most Pro Familia clinics. are immigrants, some groups of whom have high illiteracy rates and. because of their cultural traditions. sometimes have a limited knowledge of sex education and family planning. According to those working at the clinic. those obstacles were anticipated. No particular action has been taken to deal with them. Pos.1ihle themes and targets At the loca l clinic at Bornheim only four sex education themes are not rated as very important: parenthood: the psychology of puberty: the religious view of marriage and the family : and sterilization. It 1s 43 interesting to compare these answers with the view expressed by the Pro Fam ilia Bundesverband that only three themes are very important: sex ro les: the psychology of puberty: and contraceptives. At the Bornheim clinic three additional themes were regarded as important: relational problems. rape. and what were called perver- sions. Preschool chi ld ren were rated as important. though not very important. as a target group for sex education. All the other groups mentioned were rated as very important. Again the Pro Familia Bundesverband discriminated more between the potential ta rgets and claimed that children at secondary school, adolescent girls. adolescent boys. girls just below the usual age of marriage. and boys just below the usual age of marriage are important target groups. At the Bundesverband. in connexion with possible targets for family planning. it was pointed out that the official policy of Pro Familia stresses the eq ual importance of all groups. although in practical work young people are considered specially im portant. That view is obviously not shared by the Bornheim clinic. which seems to adhere more to the official policy than to the practice described a t the Bundesverba nd . The clinic claims that a ll the grou ps are important or very important as targets for family planning. Numher of clie111.1. scrrice.,· yirrn, and ji'l'S During the first eight months of I 981. 2 IO boys and 400 girls received services from the clinic. During the first te n months of I 981. the number o f adults who received services was 1200. Among the adolescents 200 boys and 300 girls received sex education. Contraceptive services were given to 20 boys and 250 gir ls. other medical services to 5 boys and 50 girls. Counselling was given to 20 boys and 80 girls. Five percent of the clients who came for contraceptive services were advised to use the condom. 15 ",. to use spermicides. and 20 °,, to use diaphragms. which were fitted. The remaining 60 ° 0 were prescribed oral contraceptives. The clinic is open from Monday to Friday from 09.00 to 13.00. and on Thursdays from 17.00 to 19.00 for sex counselling and the special counselling required in connexion with requests for abortion. On Thursdays from 17.00 to 19.00 and on Fridays from 09.00 to 13.00 there is a physician present so that the Pill can also be prescribed. The clients can either just drop in and wait for a consultation or make an appointment. When the client telephones. he or she is given an appointme nt within five days. Clients who have economic difficulties do not pay any fee for the services offered. If the client can afford it he or she is. however. asked to make some contribution. To make the clients aware that services actua ll y do cost something. yo un g people are encouraged to make a contribution at least equalling the cost of a packet of cigarettes. 44 Italy In It aly. discussions were held at the Ministry of Health and at the Centro Interna1 ionale degli Studi della Famiglia (C ISF). a Catholic orga niza tion speciali1i ng in family development and family research. Discussions were also held with a com munity-based hea lth projec t in Giugliano. Naples. Study ,·isits were made to the Family Pl annin g Association ( Unione It aliana dei Centri de Il a Educazione Matrimoniak e Prematrimoniale. U ICEMP) and their local clinic in Milan . A 5tudy \'isit was also made to the gynaecological department at Ospedale Fate Bene Fratelli in Rome. In Italy family planning in the form of contraceptive counselling was not mad e lega l until 1972. In 1975 there was additional legislati on on the establishment of government fa mil y planning clinics. The ac tual im plemen tati on of such clinics. however. depends on the local administration . Abortion was made lega l in 1978. At present there are four different proposals for legislation on compu lsory sex education . which up till now has not been given in Ita lian schools. In Italy a t present there are abo ut 400 government fa mily planning clinics. which offe r not only con traceptive se rvices but also other MCH services. The clinics are. however. unevenly distributed over the co untry: they are mai nl y found in cities. and in rural areas only in the north and central parts of It a ly. In Umbria. for instance. there is a system whereby family planning specia lis ts reg ul arly visit local health centres in the rural areas. so th at fam ily plann ing se rv ices are brought out to the countrys ide. Such services are rare in the south . The Mini stry of Heal th has no spec ial programmes fo r sex ed uca tion or family planning for young people. nor does it plan any programme for the foreseea ble future. It conside rs it more urgent to develop regular family planning serv ices open to a ll. According to an opinion expressed at the Ministry, the future deve lopment of sex educat ion, co unselling, and family planning for young people will be more the responsibility of paediatricians th an of gynaecologists, since the lat ter usually have limited cont act with the majority of young people. It was not believed that such a development would lead to competition between paediatricians and gynaecologists. On the other hand, some competition could be anticipated between paediatricians and genera l practiti oners. Paediatricians in Italy are traditionall y concerned with the age group 0- 12 yea rs and are mainly employed at hospit als or in other areas of public health , and it is believed that they would like to ex tend thei r services to adolescents. In such a case some compet ition co uld be foreseen with general practiti oners, wh o in Ita ly usually work as private practi tioners . Centro lnternazionale delgi Studi della Famiglia (CISF), Milan Owing to the special influence of the Roman Catholic Church on Italian society discussions were held at the CJSF. a private Catholic 45 orga niza tion belonging to the group Societa San Paolo. The economy of the gro up is based on the publication of a number of magazines. among which is found the most widely circulated magazine in Italy. Famiglia Cristiana. The group also possesses a radio stat ion and a TV sta ti on in Milan. The aim of the CISF. which forms on ly a sma ll part of the entire orga nizati on. is to maintain international scien tific contacts. orga nize courses and sem in ars on the family . and promote family research. The director is a priest with a qualification in psychology . The centre organizes co urses in the form of encounter groups as a part of premarital counselling. which is compulsory for couples asking for a Ca tholic wedding. During some of the sessions family planning is discussed and information given on the various methods. including those not approved by the Ch urch. The participants arc presented with a number of "case studies" and asked to give their reactions. Special emphasis is placed on natural methods but the intention . given the encounter group form. is not to tell the participants what to do but to fac ilitate their fi nding out what they wish to do themselves. The centre is a lso responsible for some ed ucation on family living, including sex education. in a limited number of schools. Since volunt ary orga niza ti ons have considerable administrative difficulty in entering the public school system. these courses are restricted to private schools. In this education information is given on all the available family planning methods . the emphasis still being on natural methods. For its teaching. as well as for its services to other Catholic counsel ling agencies. the cen tre is able to draw on a documentation centre on the family and sex uality that is probably one of the best in Europe. The centre subscribes to all the leading scien ti fic journals in Englis h. French and Italian in the field of the fami ly and sex research . It possesses all the major bibliographics and an impressive number of monograph s and educational books. It a lso regularly publishes anno- tated bibliographies. chiefly in Italian . Unione ltaliana dei Centri della Educazione Matrimoniale e Prematrimoniale ( VICEMP) UICE MP. a voluntary o rga nizati on founded in 1965. is a federation of independent family planning centres. Its main office is in Milan . Each family planning centre belonging to the federation offers the services of at least a gynaecologist. a psychologi st. a social worker. nurses. and a lawyer. Maj or centres arc loca1ed in Milan and in Turin . The main activities at the local centres are contraccpti\·e se rvices and abortion counselling. which in It aly. as in the Federal Republic of Germany. is a prerequisite to obtaining an abortion. Other activities arc sex ual counselling and therapy. pregnancy tests. and legal advice on family matters. UICEMP is the Italian member of the International Planned Parenthood Federation. Its founding in 1965 had its roots in growing discontent with the existing family planning association. the Associazionc 46 Italiana della Educazione Demografica which. according to the founders of U ICEMP, placed too much emphasis on demography and too little on individually centred fami ly planning. The older organization was also felt to have too close contacts with some manufacturers of contraceptives. Character and financiny of" proyramme Family planning and counselling for young people are the primary tasks of this clinic, although sex education for young people is a lso dealt with . The clinic is more or less permanent and will continue as long as funding is available. Each centre belonging to UICEMP has a board consisting of volunteers elected by an assembly of the members . In Milan there are about 100 individual members . Each centre is also represented by a single person in the General Assembly of the UICEMP. The total cost of the Milan clinic in 1980 was 40 million lire . For 1982 additional costs were foreseen since the clinic planned to start a special open house for young people, estimated to cost two million lire. At present the clinic is financed by fees paid by the client. the professional staff offering their services at a very low charge or no charge at all. The federation expects, however. to receive additional funds from the Lombardy region for special services subcontracted to the UICEMP, such as the counselling required in connexion with• abortions. In 1980 the clinic handled 266 such abortion counsellings. about 20 of which were for girls aged 18 years or less . In Italy girls younger than 18 years can obtain an abortion only with the written consent of the parents or through a court decree . At the UICEMP it is estimated that 98 ° 0 of the young girls obtain their abortion through a court decree, which is usually obtained quickly and without difficulty, If the local court refuses , a girl can obtain a court decree from some other town. It is sometimes more difficult to find a gynaecologist who is willing to perform the abortion; according to the UICEMP, 73 °0 of gynaecologists object to abortion on the grounds of conscience and do not perform it. For that reason illegal abortions are still not uncommon. The UICEMP does its best to refer clients to gynaecologi sts who do perform abortions. Personnel Only one secretary is employed full-time at the clinic. The remaining staff. consisting of three female social workers, a female counselling psychologist, two male psychologists, a female psychologist, four male gynaecologists. two female gynaecologists. two female lawyers, a female paediatrician, and a female general practitioner. work only part-time for the c linic. for periods varying from 4 to 24 hours a week . The salary they are paid at the clinic is con siderably lower than what professionals usually receive. For the planned open house for adolescents the UICEMP will rely heavily on the voluntary work of professionals. When possible people are encouraged to work in more than one area and to enlarge their field of competence. 47 The staff has mainly been recruited by self-selection. Formally, however. appointments are made by the board of the UICEMP. Target groups and characteristics of clients The clinic takes a special interest in young people aged 13- 18. A specia l open house programme is a lso planned for adolescents . Everyone, however. is welcome to the clinic. At present somewhat less than 20 ° 0 of the clien ts are teenagers, almost a ll girls. At the clinic clients pay for the services they receive. In principle they could receive the same services free of charge at government family planning centres. It is believed that clien ts go to the UICEMP clinic because it is less bureaucratic than the government clinics and particularly because young people feel more at ease there . According to the UICEMP, physicians working at government family planning clinics genera lly receive young people very well, but receptionists and secretaries someti mes adopt an attitude that makes it difficult for young people to be at ease . Puhlici::ing the proyrnmme The UICEMP as an organizatio n is fairly well known in It aly. The clinic adverti ses through posters . The most important way in which new clien ts are recruited. however. is through the recommendation of existing clients. In making known the existence of the services. lack of money and the abse nce of cooperation from schools have been handicaps. Ohstacles As ca n be seen from Table 10, the most important obstacles have been: that parent s of potential clien ts object to family planning for young people: that parents of potential clients object to sex education for yo ung people: that the project is opposed to traditional values: that it is not socia lly recognized that young people have intercourse: that other organiza tion s and institutions do not tell potential clients about projects: and that there is a constant risk of being forced to close owing to lack of money. Possihle themes and tarye1.1· The themes for sex education rated as important or very importent were : love : intercourse: contraceptives: venereal diseases: and sexual dysfunc- tion . The clinic added partner relations to the. list of possible themes. The o nl y two groups rated to be important as targets for sex education. in fact very important. were ado lescent girls and ado lescen t boys. When asked to ra te the importance of possible target groups for family planning services the centre rated only two groups as important: young girls as soon as possible after the menarche and young boys as soon as possible after the first emission of semen. It pointed out. however. that these ratings were made with the planned special 48 Table 10. UICEMP, Milan: rating of possible obstacles Possible obstacles Potential clients have too vague an idea about family Indication of importance• planning 2 Potential clients are hostile to family planning 1 Potential clients are hostile to sex education 1 Parents of potential clients object to family planning for young people 5 Parents of potential clients object to sex education for young people 4 General traditional values in society 4 Illiteracy 1 The uncooperative attitude of boyfriends 3 That it is not socially recognized that young people have intercourse 5 The geographical location of the programme/project centre makes it difficult to reach Business hours of the programme/project make it difficult for potential clients to get in touch 2 Other organizations/institutions do not tell potential clients about project 4 Constant risk of being forced to close due to lack of money 4 Constant risk of being closed down due to lack of political support 2 Lack of specialist personnel 1 Lack of voluntary workers 2 Lack of continued training of personnel 1 Problems of cooperation among staff 1 Lack of clearly understood objective 1 Lack of clearly defined target group 2 Lack of equipment 2 •1 = No problem whatsoever 3 = Some problem 5 = Severe problem ado lescent project in mind and that all age groups are welcome to the services ofTered . Numher o/' clients. senices yiren. and /£'es The statistics kept at the centre do not permit a detailed analysis of the clients. It is, however, known that 1341 new clients were seen in 1980, about 20° 0 under 23 years of age. Sex education was given to 150 boys and 390 girls who had not been previous clients. Contraceptive services were given to 524 girls who had not previously visited the clinic. Somewhat less than half of the girls received oral contraceptives, a 49 third IUDs, a fifth diaphragms. In recent years the prescription of pills has declined markedly because of the fear many girls have of the side efTects. The clinic is open daily from 09.00 to 11.30 and from 15.00 to 17.00. Medical examinations are available two mornings a week ar.d every afternoon. Clients usually telephone to make an appointment. They are, as a rule , seen within one week, but if there is an urgent need for a consulta tion they are seen on the same day. The fee varies with the service given . Counselling by a social worker is free of charge. A gynaecological examination leading to a prescription of ora l contraceptives costs IO 000 lire. A consultation leading to a fitting of a diaphragm costs 25 000 lire including the diaphragm . Insertion of IUDs costs 35 000 lire , including the IUD. The cost of a psychological therapy session is 15 000 lire. The fees are not fixed; if a clien t is in a difficult financial situation a substantial reduction may be given. Qspedale Fate Bene Fratelli, Rome The gynaecological department of the Ospedale Fate Bene Fratelli in Rome has had a special programme for young people si nce 1973. This programme, with special opening hours for young people, mainly ofTers counsell ing and therapy for sexual and relational problems, but contraceptive services are ofTered as well. Since 1979 these services have also been ofTered outside the hospital by people working in the gynaecological department. Of particular interest is the cooperat ion the department has establi shed with the Boy Scouts, since in Italy it is not common to give boys sex education or sexually related services. Character and financing of programme Neither family planning nor the sex education of young people is seen as the primary purpose of this special adolescent project. The emphasis is on counselling and therapy, but sex education and contraceptive services are ofTe red . In I 973 special opening hours were arranged for adolescents at the gynaecological department. At the same time, efTorts were made to ofTer more varied services, including therapy. These activities have developed since 1979, people working at the hospital now ofTering their services at a specia l adolescent counselling centre operated jointly by a number of organizations. The activities at the hospital are funded within the regular budget and costs not kept separately. The work at the youth centre outside the hospital is totally unpaid. The seven persons ofTering their services even contribute from their own pocket; recently , for instance, they paid for the printing of a poster informing people about the centre. The use of volunteers is not part of any strategy. If funds had been available they would all have been paid. 50 Personnel At the hospital the team consists of one male and two female gynaecologists and one male psychiatrist. At the youth centre they are assisted by two male psychologists (employed at a consultation centre) and one male educator (at present employed at the university in Milan). People have clear-cut areas of responsibility and there is no job rotation. The group was recruited by the head of the gynaecological department at the hospital. who originated the project. Target groups and characteristics of" clients The target group is young people aged 16- 21 years. Clients come from all over Rome but the majority are from the central parts. The clients could go elsewhere to obtain the services otTered or attend at the regular opening hours instead of the special hours for young people. They could go to government family planning clinics (which. however. do not otTer special services to young people) or to the Family Planning Association. The reason why young people go to the special clinic outside the hospital is simply stated as "We invite them and we search for them". It is believed that very few or no clients have had any previous sex education. Puhlici::iny the proyra111111e The team recently paid for a poster that will be distributed in schools. Scout centres. and parishes. Groups of young people have been reached through the initiative of teachers. and as a result of cooperation with the Boy Scout Movement about 30 °0 of the clients to the clinic outside the hospital have been boys. The consultations with the boys have usually centred on fear of impotence and of not being normal. The major obstacles to publicizing the programme have been lack of money and lack of cooperation from schools. Ohstac/es As can be seen from Table 11. only one of the possible obstacles has been rated as more than a mere problem : the fact that it is not socially recognized that young people have intercourse. That. in spite of the difficult economic situation for the clinic outside the hospital. none of the other obstacles listed was rated as a serious problem is probably attributable to the fact that. according to the team. all the obstacles encountered were anticipated. Possihle themes and taryets Of the possible themes for sex education only four were not rated as important or very important but as of some importance only: pornography: intercourse: venereal diseases: and sexual dysfunction. All the possible target groups for sex education listed were rated as very important and included : adolescent girls: adolescent boys: girls just below the usual age of marriage: and boys just below the usual age of marriage. 51 Table 11 . Ospedale Fate Bene Fratelli , Rome: rating of possible obstacles Possible obstacle Potential clients have too vague an idea about family plan- ning Potential clients are hostile to family planning Potential clients are hostile to sex education Parents of potential clients object to family planning for young people Parents of potential clients object to sex education for young people General traditional values in society Illiteracy The uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme/project centre makes it difficult to reach Business hours of the programme/project make it difficult for potential clients to get in touch Other organizations/institutions do not tell potential clients about proiect Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of political su pport Lack of specialist personnel Lack of voluntary workers Lack of cont inued training of personnel Problems of cooperation among staff Lack of clearly understood objective Lack of clearly defined target group Lack of equipment •1 = No problem whatsoever 3 = Some problem 5 = Severe problem Indication of importance• 3 3 3 2 1 1 4 3 3 3 1 1 2 2 3 3 3 When asked to rate the possible target groups for family planning and counselling on ly two groups were rated as very important: yo ung gi rl s as soon as possible after the menarche and young boys as soon as possible after the first emission of semen. Girls and boys just below the usual age of marriage were considered to be of some importance as targets, whereas all the remammg groups were considered as not important. Number ol c/ie111.1·. sen ices yiren , and ./£'es Statistical records at the hospital are not presented in a way that makes it possible to know the exact number of clients seen under the ado lesce nt programme. At the youth clinic o ut side the hospital 100 boys and 200 girls were seen for sex education. and 20 girls also received 52 i:ontraceptives . That not more girls were given contraceptive services is believed by the team to be because gir ls wishing only to obtain con traceptives go tirst to the Family Planning Association . The problems at the youth clinic arc more psychologica l than contraceptive. As regard s contraceptive methods advised o r prescribed. the first suggestion of the c linic is the Pill. It believed . however, that condoms and coitu s interruptus are used mo re often than the Pill. The yo uth clinic is open for consultations o n one afternoon a week . It is. howe\'CL poss ible to telephone to the clinic for an appointment at any time during the week . At the hospi tal th e specia l o utpa tient clinic for yo ung people is o pen for one mo rning a week . Clien ts who have te lephoned for an appointment are admitted almost immediately. i.e. o n the nex t consultation day. At the hospit al client s pay a fee of 8000 lire. At present th ere ts no charge for services at the yo uth clinic . There ha ve. however. been discussions about introducing a small fee since it is believed that some yo ung people fear th at there are strings attached if the se rvices are offe red free. Centro di Medicina Sociale, Ciugliano, Naples Discussions were also held with the sta ff of the Cen t ro di Med icina Socia le. Giugliano. Giugliano is the name of one of the boroughs that. together with six o thers. form the commune of Giugliano on the outskirts of Naples. The borough of Giugliano has 45 000 inhabitants. the commune 150 000. The centre started in 1975 as an experiment. at a time when the commune had a left-wing local government. The centre has now been incorporated into the health structure and is formally an ordinary hea lth centre. The commune is now governed by the Christian Democratic Party. The ac ti vi ties of the centre are based on the view that it is necessary to mobilize the population to tackle socia l problems actively in order to improve socia l conditions: family planning and sex education are not seen as goals in themse lves. Family planning is offered to women as part of primary health ca re and some sex ed ucation ha s been given to young people. It has. however . been felt more important to mobi lize young people to take act io n themselves: thus a campaign was organized by the girl s in one schoo l, wit h the aid of the centre. to force the local cinema to show other than pornographic films. Th is campaign is typical of the way people a t the centre try to mobilize the population to deal with issues felt to be relevant by the population itself. For this community-based approach the cen tre is heavily dependent on the cooperation of vo luntee rs. It tries to cooperate with organiza tions already existing such as trade unions. People in the community are abo mobilized to form pressure gro ups. with the intention of creating a core of citizens able to carry o n the work originating in the centre. About 500 women receive family planning services through th e centre. Of these 30- 40 °0 are estimated to be below 20 years of age. 53 Young people are. however. not seen separately. Although th e centre ofTers famil y planning se rvices. those who work with it do not primarily consider themselves as service providers. Unlike the other projects and programmes studied. the primary purpose of the Centro di M ed icina Socia le in Giugliano is not th e provi sio n of se rvices: services a re seen as a means whereby people can be mobilized to fight against adverse soc ial condition s. This approach has in a number of in s tances led to conflic t with the local a uth or ities. Owing to the s upport of the po pulatio n the centre has nevert heless been able to continue its work . Morocco In Morocco discussions were held with the Po pulation Di vis ion of th e Mini stry of Hea lth . the Commission on the Status of W o men. a nd represe ntati ves from the Mini stry of Youth a nd Spo rt and the Mini stry of Education . Discussions were also held with the Association maroca ine de Planifica ti o n familiale (AMPF). the Morocca n Family Pl a nning Association . Study vis it s were made to the fa mil y planning centre in Rabat and to a mobile MCH unit in Kh em isset di strict. Since no special family planning activities for young peo ple ex ist. data on programmes or projects we re no t collected by questionnaire but solely during di scuss io ns a nd study visi ts. Moroccan soc iet y is the product of a number of traditions . One of the mos t impo rt a nt is Mu slim . mai nl y patriarchal. A part of the population 1s. however. of Berber o ri gin. Contacts with ot her Mediterranean countri es have been numerous and th e country has been grea tl y influenced by France. The culture. mainly rural. ha s in recent decades been affected by rapid populati on increase. indus tri a li1a ti o n and urbanization . Almost 60 "., of the population a re under 20 yea rs of age. For heal th care administration the cou ntry is diYided into 42 provinces. in each of which there is a heal th ed ucator who has audiov isual equipment and teaches health educat io n. including family planning. In 13 provinces. wit h in which 80 "., of the population liYe. there are special famil y planning centres. The Population DiYision of the Ministry of Health estimated recently that 14 "., of women in the rcproductiw period use some kind of family planning . The Ministry of Health does not run any special family planning cli nics for yo un g people. nor does it arrange for sex educat ion to young people in particular. From discussions at the Study and Planning DiYision of the Minis try of Ed uca ti on it appears that there is no suhject entitled sex education in the Moroccan school curriculum. Some education on sexually related ma tt ers is. howc\Cr . gi\-cn as a part of the teaching of the natural sc iences. the instruc tion basically related to reproduc ti on being given in the four th year of secondary school ~ hen the pupils arc 16 17 1cars old. There is no special teaching material in sexuality. T he Ministry of Youth and Sports cooperates ~ith !'Association marocaine de Planification familialc in a special yo uth project . The 54 Ministry is responsible for the youth centres that exist in many places in M orocco. At these youth centres the Family Planning Association has educational groups for young people. L 'Association marocaine de Planification familiale The Family Planning Association in Morocco is a voluntary organization almost entire ly funded by the International Planned Parenthood Federation. but it has important official support. The Minister of Health is chairman and one of the royal princesses an honorary chairman. The economic support from the Government is merely symbolic: more important is the support it g ives th rough the instruction to all government agencies concerned that they shou ld facilitate the work of the Fam il y Planning Association and wherever possible let it use the staff and premises of the agencies . The most important government partners for the Association are the Ministry of Youth and Sports and the Ministry of Ed uca ti on. The former is responsible for youth centres. of which there arc 114 in Morocco. The Family Planning Association organizes educational groups for boys and girls aged 16 in the centres . The Association also organi1es special educational courses for men. usually in factories. and for people working in key positions in ministries and in local administration. The Family Planning Association has four particular target groups for its educational efforts: women at the reproductive age: men: youths. and people in key positions. Sex education. according to the Association. ought to include much more than reproduction and contraception. Education in these matters should facilitate the incorporation of sexuality into the personality and be given continuously during life and in all the contexts where sexuality might be an issue. Information. education. and discussion on sexuality ought to be a part of life itself. The Family Planning Association is active in five of the country's seven regions. Each of the regions has been divided into a number of small provinces and in each province there is a mobile family planning unit with a driver. a midwife. and some educators. This team travels the province according to a timetable drawn up six months in advance . When asked about the chief obstacles in their work the following problems were mentioned : - Religious opposition. Certain groups interprete the Koran in a way that makes them opposed to almost all kinds of detailed planning. since this is felt to interfere with the ways of God. The opposition is not only to family planning but al so to most departures from traditional ways. - A tradition of resignation. which is sometimes a part of the cultural pattern. - The view in rural areas that many children are an asset in the household. 55 - The weak legal position of women. Since men can easi ly obtain a divorce in Morocco it is believed that women often try to attach the husband closer to them by having many child ren: this does not mak e a divorce any more difficult legally but the women hope that it will be more difficult socially. - The lack of genuine interest on the part of some political parties in fami ly planning. Family planning is part of official government policy. but it is not carried out as vigorous ly as the Family Planning Association would wish. In connexion with the las t point. it is an integral part of the strategy of the Famil y Planning Association to maintain access to people in key positions. to convince organizations and political parties of the benefits of family planning. In spite of the semi-officia l position of the Association. which ha s the Mini ster of Health as its chairman. it also coopera tes with the opposition parties. The Family Planning Association has been active since 1971 . Family planni ng activities had . however. started already on a broader scale in 1966. when a health cen tre speciali1ing in family planning opened in Rabat. Centre de Reference ( Referral Centre), Rabat Family planning within the national health sys tem is organized in Morocco at three levels. The first consists of dispensaries. of which there arc more than 200 in Morocco. usually serving a population of about 15 000 . These dispcnsa rics off er a va ricty of primary hea Ith ca re services. In relation to family planning they deal with motivation. education. and the prescription of contraceptive pills . Usually the dispensaries arc not regularly staffed with physicians . The next lcYcl in the health care hierarchy is constituted by the health centres. of which there is one to every 45 000 population. or one to each three dispensaries . At a health centre there is at least o ne physician . Besides the sen ices offered by the dispensary the health centre inserts IUDs. More complicated family planning cases arc referred to special referral centres or centres de reference. of which there arc 13 in Morocco: ten more arc planned for th e next two years. A study visit was made to the referral centre in Rabat. which started in 1966 under the name of Centre de Planning familial. The centre in Rabat secs about 100 women daily. About 15 °., of these women come direct to the centre. while 85 ''., have been referred to the centre by dispensaries. health centres. hospitals. or private practitioners . All the social classes arc represented . since these reference centres ha,·c an excellent reputation and are speciali1cd in family planning. At the centre in Rabat the staff consisted of three midwives working full time and three gynaecolog ist s working part time . Most of the women who come to the centre are between 18 and 30 years old and have at least two children. There are also a small number 56 of women who have no child ren. Young unm ar ried women are ve ry se ld om clients: those who do come have usuall y been refer red to the centre by a social work er who has some specia l reason to send them. The contracepti ve most often used at the centre is the IUD: this is a result of the clinic being a specia lized clinic. All other cont raceptives are usuall y prescribed with out any pro blems a t the di spensa ries o r hea lth centres. Seventy-five percent of the cl ient s a t the centre were using IU Ds. The first check -up after an insertion takes pl ace after one month : la ter check-ups take place every six month s. For ora l cont racepti ves the firs t presc ription is for one month . la ter on fo r three months a t a time. In Morocco th e lega l sta tus of sterili za tion is unclear: some steriliza ti ons are perfo rm ed. howeve r. No sterili za ti ons are perfo rmed at this clinic: when a sterili za tion is perfo rmed it is done a t a hospita l. Onl y women are sterili zed: vasectomies a re not ca rried out in Morocco. In moti va ting cli ent s and potenti al cli ents to adopt fa mil y pl annin g the emphasis is entirely on the hea lth aspect s and the poss ibility of pl anning and spac ing births. Th e populati on aspec ts a re not menti oned in the educati on given at the centre. The educa ti on also foc uses on cont raception: sex ualit y in genera l is not touched upon. The cultural background and the traditiona l positi on of women make it diffi cult fo r women to discuss sexu alit y in groups. but sometimes a woman brings up a sexual pro bl em when ta lking priva tely to a ph ysician or mid wi fe. Sex ual dysfuncti on is. however. believed to be frequent. It should be noted tha t the lega l age of marriage fo r women is 15 yea rs and fo r men I 8 yea rs: th e low lega l age of marriage is accompanied by ea rl y marriage. This explains in part wh y so few unmarried client s come to the cl inic. Given the cultu ra l backgro und . too. it is ve ry difficult fo r young unma rri ed persons to ackn owledge publicly that they have a sex life. which is wh at a visit to the refe rra l centre wo uld mea n. It has been es timated by WH O (7) th at about 90 °., of women are marri ed by th e age of 19. Polygamy is lega l in Morocco alth ough not ve ry oft en practised . Today it is practi sed ma inl y in some rural communities a nd sometimes among immigra nt s who have one wi fe in Morocco and a nother in Euro pe. Mobile family health unit, Khemisset district In ru ra l di stricts with a low popul ation densit y MCH se rvices are offered by mobil e unit s to mothers and children below two yea rs of age. The children are vaccinated and receive trea tment fo r infec ti ons. and milk and dehydra tion sa lt s are di stributed . famil y plann ing se rvices are also included: besides moti va ti on and educa tion. the Pill is prescribed and th e in se rt ion of I U Os offered . The tea m workin g with the mobil e un it consists of two nurses. of wh om one has been speciall y tra ined in family planning and is able to inse rt IUDs. an ass istant nurse. and a dri ve r. The mobile MCH unit usually stays one day and one ni ght at each stop. then moves on about 57 30 km to the nex t stop. returning to the same pl ace after 6- 7 wee ks acco rding to a prev iously es tabli shed timetable. The team work s fo r five days a wee k. and on Sundays retu rns to the hea lth centre to replenish su ppli es and stcrili1e equipment . After three months th e tea m is cha nged. since th e work is demandin g a nd the mobile unit is it s home fo r mos t of th e three month s. Durin g the night and in th e ea rl y hours people had a rrived a t th e pl ace wh ere the mobile unit was to be fo und . In the a rea visited there were abo ut 1550 inh abi ta nt s. On th at day. as on mos t da ys. fa mily planning ass istance was give n to some 40 women. a nd medica l se rvices were offered with the fa mil y plannin g se rvices. At night th e team showed fi lm s on hea lth ed uca ti on and fa mily plann ing. Durin g the day th e loudspea kers of the mobile unit we re used sporadica ll y to prov ide taped info rmation on vacc ina ti on. nut rition. and fa mil y plann ing. th e three a reas in which the mobile uni t is specia li zed. There we re no specia l se rvices fo r yo ung peo pl e and th ere cou ld hardl y be any. since participation by them wo ul d be immedi ately observed by the entire communit y and so remove one of th e mai n reasons fo r offering services to yo ung peopl e. th at they co ul d recei ve the se rvices with out oth er peo ple kn owin g. The Famil y Plannin g Associa ti on in Morocco also opera tes mobile famil y pl a nn ing unit s. Th ere are several differences between th e mobile unit visited . which was opera ted by the Ministry of Hea lth and funded prim aril y by U]'; FPA. and th ose of the Famil y Pl anning Assoc ia ti on. The mobile un it visited offered comprehensive M CH services. which th ose of the Fa mil y Planning Associa ti on do not. The mobile fa mily pl anning unit s of th e Associa ti on spec ia li ze in fa mily planning and offer motiva ti on. educa ti on. and the prescr iption of the pills. while the mobile unit s that belong to the Ministry of Hea lth offer. bes ides a more comprehensive hea lth se rvice. a wider choice of cont racepti ves. since th ey a re abl e to in se rt IUDs. The Netherlands In the Netherl and s study visit s were made to Rutgers Stichting and to the Mello projec t. Di scussions were a lso held a t the Ministry of Hea lth (see Annex 6 fo r li st of persons met. ) The Mini stry of Hea lth is res ponsibl e to a limited degree only fo r fa mil y pla nning and the sex educa ti on of young peopl e. mos t of the responsibility fa lling on the Mini stry of Ed ucation. The Ministry of Hea lth is. however. responsibl e fo r school hea lth . The school hea lth system is considered to be severely understa ffed and thu s has ve ry limited opportunities fo r prov iding the yo ung with sex educa tion or fa mil y planning advice. The majo rity of ph ysicians ac ti ve within the sc hoo l sys tem would probabl y prescribe ora l contracepti ves if they were asked to do so by young peo pl e. Young people a re, however. more likely to go to pri va te physicians or to a private fa mily planning associ a tion. 58 In the Netherlands the morning-after pill is used more often than in most other countries. The Rutgers Stichting has. for instance. special opening hours during Saturdays and Sundays for the distribution of morning-after pills. This practice has not been debated and even religious fundamentalists. who otherwise oppose various sexually related services to young people. do not seem to regard the morning-after pill as an early abortion. Given the comparatively frequent use of the morning-after pill, abortion rates in the Netherlands are comparatively low. A third of the abortions are performed on foreigners, who come to Holland in order to obtain the abortion they would have trouble in obtaining in their own country. Abortions are easily obtainable in the Netherlands although, according to a nineteenth-century law. they are illegal. This law. however, is about to be changed and abortions made legal. The new law is very liberal. but the fundamental difference between present practice , according to which the decision rests entirely with the woman, and the proposed practice in which the decision is made by the physician. has led to considerable debate. According to the proposal at least five days must elapse between the day of initial contact and the day the abortion is performed . In the Netherlands the overwhelming majority of the population are covered by a social security system. those with low incomes fully and those with higher incomes partially. Those covered by this insurance can go to a general practitioner without cost. Young people. however. are often reluctant to resort to a general practitioner in their district to obtain contraceptives since they fear that the general practitioner will tell their parents. General practitioners also sometimes lack training in family planning and gynaecology. Young people therefore generally go to Rutgers Stichting or some other family planning agency for contraception . The majority of Rutgers Stichting's clients are neverthe- less more than 20 years old. even though the proportion of younger clients continues to raise . Rutgers Stichting has been. and is. cultivating the image of being a provider of services to young people. The legal minimum age for intercourse in the Netherlands is 16 years. Young people are. however. never prosecuted if they have intercourse even if one of them is younger than 16. As regards the age of consent and contraceptive advice. a widespread view. tacitly supported by the authorities. is that if a person is old enough to have a problem he or she is also old enough to give consent. This very pragmatic interpretation of the concept of age of consent has been found to work in the Netherlands without known complications . Sex education is not compulsory in the Netherlands. It will. however. be strengthened by a new education bill. which puts greater emphasis on education on health and on living together. The bill has met some opposition from religious fundamentalists. who do not usually oppose medical family planning services since they are perceived as being primarily technical. More opposition is usually found against sex education. which is believed by the fundamentalists to stress sex unduly as a pleasure-seeking activity. The opposition to sex education and the 59 general ignora nce about the subject have led to a great demand for information . Rutgers Stichting receives 120000 phone calls yearly from people seeking \ 'Cry simple information. In the Netherlands there are a lmost half a million inhabitants of non- Dutch origin. and in some residential areas 100 °., of the schoolchildren are of foreign origin. often from the former Dutch colonies. There are no specia l sex education or family planning programmes for these people. Since abortion figures arc ri si ng in these groups special programmes ought to be considered. particularly for the young. since in many cases they mu st be \'icwed as \'ictims of the clash of cultures. Rutgers Stichting In the Netherlands the two major family pl anning associations are Rutgers Stichting and NYSH (Nederlandsc Ycreniging voor Seksuele Hervorming- Nctherlands Union for Sexual Reform) . Am ong other smaller o rgani za tions arc a number of Roman Catholic marriage counselling age ncies. a Protes tant foundation for promoting responsible family-building. and orga ni7ati ons special ly devoted to counselling homoscx ua ls. The Rutgers Stiching a nd the NYSH have a common origin. In the late I 960s a difference arose in the NYSH between advocates of a lternative forms of sex life and those whose interest was mainly effective family planning. This led to an organizational split in 1969 . The service- providing centres were orga nized by the Rutgers Stichting and the NYSH continued its activi ty under the sloga n .. sex ual revolution ... Membership of the NYSH declined from well ove r 200000 to about 35 000. Later. however. the NVSH become convinced that the split between social reform and practical aid was harmful to both activities. and it once more se t up practical aid centres of its own . The newly formed Rutgers Stichting had meanwhile expa nded its limited con- traceptive services to include counselling and educational programmes. The Rutgers Stichting is a foundation with a se lf-recruiting board of nine persons who a re not empl oyed by the o rga niza tion . The board does not interfere with the daily work of the foundation. which is organized by five full-time staff at the main office in the Hague- a gerieral director and four officers for education and public it y. psychotherapy. personnel. and finance respectively. At the main office there are another 19 administrators. sec ret ar ies. and o ther office staff. In all there are 400 persons employed by the Rutge rs Stichting. a ll except those at the main office part-tim e. Rutgers Stichting has 46 local unit s all over the Netherlands. called Rutgershuis . 7 large. 15 medium-sized , and 24 small. A large Rutgershuis offers, besides contraceptive services, psychotherapy and education: a medium-sized one contraceptive services and therapy, and a small one contraceptive services only. The aim is that all Rutgershuis should offer a complete range of services. During the past year 20 very small units have been shut down. The Rutgers Stichting is financed ma inly by public money provided 60 by the Government (sec below). By comparison. the NYSH does not receive any public funds at all. The probable explanation is that it is politically more acceptable to the Government to support an organiz- ation whose image is that of a professional service-provider than an organization whose image is one of political activism. The total budget of the Rutgers Stichting is about D.fl. 9 million yearly. 66 °., of which (meeting all the wages costs) is covered by public funds. most from the Ministry of Social Affairs but some from the Ministry of Health and the Ministry of Education. Of the rest 30 °., is covered by fees from clients and the remaining 4 °., by interest and profits from publications. In the Netherlands there thus seems to have developed an entrepreneurial system where the Government pays for activities it views as important but prefers to keep outside the political sphere. A recent experiment with sex education for preschool children is typical of this entrepreneurial system. The entire experiment was funded by the Ministry of Education. but the report will be published by the Rutgers Stiching. not by the Ministry. Rutgers Stichting ec/11catio11a/ deparrment Character o(progra111111e and financing. The educational department. a permanent department. is responsible for the educational efforts of the Rutgers Stichting in the whole of the Netherlands. Six educational teams work in the country. The wage cost for the educational programme is D .fl. 100000 a year. To this must be added another D.fl. 100000 a year for publications. etc. The educational programme is funded entirely from government money . Personnel. Working with the programme are the educational officer and 25 paid part-time non-professionals. The educational officer. male. works full-time: the 25 part-time educational workers. all female. work for approximately ten hours a week. That they are all female is not the result of any particular policy but rather of the fact that the work is part-time and not particularly well paid. People have clear-cut areas of responsibility and there is no job rotation. The staff is recruited by public advertisement of vacant positions and selection by a recruitment committee. The same procedure will be used if more people are employed. Target groups and characteristics of" clients. The target group for the educational programme is usually described as young people, by which is meant people in the age group 12- 20 years. About three-quarters of those who attend Rutgers educational programmes are below 20 years of age . Three-quarters of those seeking contraceptive services from the Rutgers Stichting are over 20 years old. Education is organized either through attendance at educational groups in a Rutgershuis or through educational teams going to schools when invited and providing sex education during school hours. It is believed that some, but less than the majority. of those attending the educational programme have had previous sex education. the usual 61 source of which is school. The Rut gers Stichting believes that. because of the more flexible curriculum in primary schools. more sex education is given in primary than in secondary schools. Sex education is not compulsory in the Netherland s but some teachers provide sex education. Young people could go elsewhere for sex education and schools could ask other groups than Rutgers to g ive sex education within the school. but it is believed that Rutgers has an image of being neutral and professional rather than activist or associated with some particular creed. It is also believed that Rutgers is sometimes prefe rred because of the comprehensive se rvices it offers s ince it is able to provide counselling se rvices as well as contraceptive services. Puhlici::iny 1he proyramme. The Rutgers Stichting is widely known in the Netherland s through it s participation in a number of radio and TV programmes. It also la unches commercial publicity campaign To make it s educational programme known it dis tributes lea flet s as far as possi ble whenever school organizations have meetings. It is also often able to put up posters in schools . The local educational team s also advertise themselves by approaching school officials in their di strict directly and o ffering their se rvices. The most important obstacle to bringing their existence to the knowledge of potential clients has been lack of funds. Although additional funds would have facilitated the work, the present budget. according to the Rutgers Stichting. ha s had no untoward ef- fec ts. Ohs1ac/cs . The mos t important obstacle perceived by the foundation is that the educational gro ups are not given sufficient time in schools for their programm es. Usually they are given two hours for each class: they would. however. prefer to have time regularly allotted during an entire school year. The time available not only puts strict limit s on what can be taught but also makes the integration of sex education into other subjects almost impossible. To overcome these difficulties the Rutgers Stichting contacted the Ministry of Education. and it hopes that its views will be taken into consideration by a curriculum planning committee functioning a t present. The educational officer was asked to indicate which. if any. of a number of poss ible obstacles were se riou s problems for the educational programme. The result is presented in Tab le 12. As can be seen from the table. none of the possi ble obstacles was perceived as a se rious problem for the educational programme. For the sake of simplicity the answers from the local Rutgershui s in The Hague have also been incorporated in the table . TI1e differences shown in the rating of obstacles are minor. Neither the educational department nor the loca l Rutgershui s in The Hague regards any of the obstacles mentioned as a serious problem. Possihle 1hemes and 1arye1s. In the discussion about government views on sex education and family planning. data were presented on the ratings of various themes in sex education and poss ible target groups fo r sex education and family planning (see Tables I. 3 and 5). Comparable data are available for each programme or project. and will be 62 Table 12. Rutgers Educational Department and Rutgershuis, The Hague: rating of possible obstacles Indication of importance a ~tg ers Educational Possible obstacle Departm ent Potential clients have too vague an idea about family planning 3 Potential clients are hostile to family planning 2 Potential clients are hostile to sex education 4 Parents of potential clients object to family planning for young people 2 Parents of potential clients object to sex educa - tion for young people 2 General traditional values in society 3 Illiteracy 2 Uncooperative attitude of boy friends 3 That it is not socially recognized that young people have intercourse 2 The geographical location of the programme/ project centre makes it difficult to reach 2 Business hours of the programme/project make it difficult for potential clients to get in touch Other organizations/ institutions do not tell potential clients about project Constant risk of being forced to close due to lack of money 3 Constant risk of being closed down due to lack of political support 3 Lack of specialist personnel 3 Lack of voluntary workers 1 Lack of continued training of personnel 3 Problems of cooperation among staff 1 Lack of clearly understood objective 1 Lack of clearly defined target group 1 Lack of equipment 2 • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem. Rutgershu1s 4 2 3 4 3 4 4 2 2 2 2 2 4 2 2 1 3 1 1 2 2 summarized and discussed in a later chapter. A few comments will be made for each individual programme. The most important themes in sex education . according to the Rutgers education department. should be sex roles. love. petting. and masturbation. The least important are the psychology of puberty and the religious view of marriage and the family . The groups it is particularly important to give sex education to are children at secondary school. 63 adolescent girls. adolescent boys. girls just below the usual age of marriage. and boys just below the usual age of marriage. The education department makes no distinction between groups that it is important to reach with family planning services . All are equally important. Numher of clients and /<'es. Sex educat ion was given to about 22000 persons during the previous 12 months. hal f of whom were boys and most in the age bracket 13 - 20 years . That boys were seen as often as girls is due to the fact that most of the education took place in ordinary schools . Those who receive sex education never have to pay for it. but institutions that have asked for it pay a negotiable fee. R111yers/111is. The 1/ayue C/ul/"acter mu/ fi11a11ci11y of proyrn11111w. The Rutgershuis in The Hague is one of the major centres of the Rutgers Stichting and otTers family planning services. counselling. sex therapy. and education. Within the Rutgers Stichting there arc six clinics of this si7e and a number of smaller family planning clinics . The clinic is permanent and its activities arc planned on a long-term basis . Like the entire Rutgers Stichting. the clinic is dependent on government grants for survival. The total cost for this Rutgcrshuis in 1980 was D .fl . 900000 . Financing is the same for all the Rutgcrshuis: thus all the salaries arc paid out of government funds and amount to 66 ° ., of total costs . An additional 30 ° ., of the budget comes from fees paid by clients . 4 °., from interest and profits on sales of publica- tions. Perso1111d All the people working in the clinic arc paid for their services. The staff consists of ten general practitioners. of whom five arc female. who work from 3 to 12 hours a week . All ten prescribe contraccpti,c pills . whereas only four insert IUDs . There is also a midwife. who performs gynaecological examinations. measures for diaphragms. and carries out pregnancy te sts . She works for four hours a week . For sex therapy there is a female social worker. a male psychiatrist. th rec ma le psychologists. and a fem a le psychothcra pist. who all work part -time from IO to 30 hours a week . Six receptionists and three administrators work half-time to full-time . No volunteers arc used . The statT is recruited by advertisement and selected by a recruitment committee . Taryet yroups anti charnneristics of clie111s. No particular target group is aimed at by the Rutgcrshuis in The Hague: everyone is welcome. The Rutgcrshuis . however. has the image of catering primarily for the young. an image that does not correspond entirely to reality since the majority of their clients arc more than 20 years old . But increasing numbers of young people visit the clinic. a quarter of the clients now being younger than 20 years of age . For contraceptive services clients could have gone to general practitioners and for contraceptive services combined with ad, i~ory sen·icc~ to the VSH. but at the Rutgcrshuis belic,·es that they go to it because the statT arc "nicer". gi\'c them more 64 time. and have better knowledge and a greater ability to handle their problems. The majority of the clients arc thought to have had sex education before their contact with the Rutgershuis. either through school or through the Rutgers educational department. P11hlici::i11y rhe proyrnmme. The Rutgershuis relics mainly on the general information campaigns of the Rutgers Stichting. which include posters. leaflets. and appearances in various radio and TV programmes. It is not felt that any problems or obstacles have been encountered in efTorts to make the programme known. The most important factor in the recruitment of clients is thought to be the recommendations of friends who are already clients. Ohsracles. None of the possible obstacles discussed (Table 12) were found to be a serious problem for the Rutgershuis . The only obstacle com mented upon was the limited financial resources available. To overcome this problem discussions were held with the Ministry in order to increase the funding so that the Rutgershuis could continue to assist young clients especially. For some years now the fee for young clients has been considerably less than that for adults. Possihle rhemes and raryers. The most important themes in sex education. according to the Rutgershuis in The Hague. are sexual anatomy. sex roles. love. masturbation. venereal diseases. and abortion. All the possible target groups for sex education and family planning are seen to be of equal importance. Numher of c/ienrs , serrices yiren and /c' es. During the preceding 12 months about 100 boys. 2000 girls. and 6500 adults were seen at the clinic. Twenty boys received contraceptive services. 50 other medical services, and 30 counselling: 1700 girls received contraceptive services. 250 o ther gynaeco logical or medical services. and 50 counselling. Virtually all the young girls who came for contraceptive advice were given contraceptive pills. As regards the clients as a whole. including adu lt s. the distribution of contraceptives advised or prescribed is somewhat different: I 0 0 were recommended condoms. 5 °,. diaphragms to be used together with spermicides. 10° ,, IUDs. and 77 ° ,. oral contraceptives. Long-acting injectible contraceptives were given to 2 ",. and sterilization performed on 5 ° 0 . When making initial contact with the Rutgershuis a client usually first phones for an appointment. which is generally given within two days. When the client arrives at the reception desk he or she is seen by a nurse who explains about the clinic and carries out any necessary tests. If a prescription is necessary the client then sees a physician. The cli en t is asked to return after three months for a first check-up and then every six months. Consultations usually take from half-an-hour to one hour . The Rutgershuis in The Hague is open for all its services in three shifts: 09.00 - 12.00: 13.30 17.00: 19.00- 20.00 . On Wednesdays all the services arc available from 09.00 to 12.00 and from 19.00 to 20.00. on Fridays from 09.00 to 12.00 and from 13.30 to 17.00 . During weekends the Rutgershuis is open for an hour daily for morning-after pills and 65 emergency need s for ordinary contraceptive pill s. The fee for contraceptive advice as well as for counselling or therapy is D .fl . 7.50. The Mello prnject The Mello project. which received it s name from the initials of the Dutch words for .. lea rning to ge t along with one another ... is a resea rch and deve lopment project. the project leader being attached to the University of Groningen. The purpose of the project is to develop techniques that can be used to change stereo typed role pla ying and facilitate communication between pupil s and teachers. The target group is pupils at secondary school. which in the Netherlands means adolescents from 12 to 18 years of age. The project is based on the findings of numerous studies that yo ung people frequently have important problems. namely: - difficulty in communicating with others - feelings of uncertainty and tensi on - difficulty in integrating sexuality into their personality - perception of the difficulties in communicating. The purpose of the project is to develop suitable techniques so as to: - increase their se lf-confidence - increase their insight into communication and interaction - increase their ability to differentiate perceptions. The project statT have worked since 1977 in two schools in the Netherlands . Besides training pupils. the project started special training courses for teach ers in 1981 . the aim being to develop a course that can be integrated into the future education of teachers. When the project was initiated in 1977 invitations to participate were sent to all secondary school s in the no rth of Holland. Ninety-four percent of the schoo ls did not answer: 6 ° 0 showed some interes t. In the original plans there was a poss ibility of 24 schools participa ting. The project is now act ive in six schools. None of the participating schools recruits pupils from high-status areas. According to the project leader. this shows that what he calls .. lower-level schools .. are much more interested in trying to integrate personality int o education and in moving away from a narrow intellectual education. The project is of a kind that is often described as action research . It is planned to invite women's groups to participate in the special courses for teachers since this is felt to be a means of developing techniques for the release of non-intellectual resources among the teachers . Character and financing of' proyramme. The purpose of the pro- gramme is to integra te a number of personality-developing aspects into the school curricula. Among them are a number of issues relevant to sexuality. Sex education as such is not dea lt with within the programme since the purpose of the project is to integrate aspects into the curricula rather than to add another subject. The project is an experiment and will not. unless otherwise decided , 66 continue indefinit e ly. It has grown out o f prev io us studies conduc ted by the projec t leade r. The p rojec t is funded entire ly by the Ministry of Ed uca tio n . Th e to ta l cos t for 198 1 was D .fl . 295000. some 75 - 80 11 11 of which goes on sa laries. Vo lunt a ry wo rk by stud ents is impo rt ant fo r the success of the prog ramme. The student s a re. however. d o in g wo rk th a t in principle could have been just as well do ne by p ro fess io na ls if suffic ient fun di ng had been avai la ble . Personnel. Fo ur sa la ried people wo rk o n the p rog ramme. two full - time. the o the r two sha ring a thi rd pos t. At present there is a lso one student wo rking full -time. Th ose who dev ised the projec t initia ll y se lected the firs t empl oyees who la ter pa rt ic ipa ted in the se lectio n of the res t o f the stafT. th ough the for m a l appo intment was by the p roject leade r. The sa me p rocedure wo uld be used fo r new sta fT members. Targe t yroup and charactcristics . T he project wo rks with two gro ups o f people: pupil s a t h igh school aged 12- 18 yea rs and teache rs in h igh schools . Th e projec t functi o ns in s ix schools in th e th ree no rt he rn provinces o f the Netherl ands. Puhlici::: ing thc programme. T hose wh o wo rk wi th the progra mm e say th a t they have had considera ble problems in comm un ica ting the ex istence o f the p rog ramme to the po tenti a l use rs, i.e . schoo ls. Very few schoo ls replied when invited to parti ci pa te in the p rogramme beca use. the project sta fT believe. o f lac k of wh a t they ca ll ed rea l coopera ti on from the schoo ls. By th is is mea nt tha t the schools we re o bvio usly much less interes ted in th e p rogra mme tha n was ant ic ipa ted . N11111hcr of clicnts . Ten ma le and fo ur fe ma le teachers partic ipa te in the deve lopment of th e educa t iona l p rogra mme toge ther with their pupil s. abo ut 500 boys a nd girl s. Seven ma le a nd three fe ma le teachers pa rti c ipate in th e spec ia l co urses fo r teachers. Beca use of the cha rac te r of th is research a nd d eve lopment project and beca use ne ither fa mil y pla nning se rvices nor sex ed uca ti o n a re o fTered. the questi ons o n possib le themes a nd ta rge ts fo r sex ed uca tion in fa mil y pl annin g we re om itted. Poland In Pola nd stud y visit s we re made to the Depa rtmen t of Fa mil y Hea lth of the N a tio na l M a te rna l a nd Chi ld Hea lth Resea rch In st itut e a nd to the famil y pla nnin g clinic of the Polis h Pl a nned Pa renthood Federa ti on (Towa rzys two Rozwoj u Rodzi ny) in Wa rsaw. Discuss io ns were a lso held with a represent a ti ve a t th e na tiona l leve l of the Famil y Pl a nn ing Assoc ia ti o n and with the cha irm a n of a former gove rnment co mmittee o n sex educa ti o n. The Department of Famil y Hea lth of the N a tio na l M a terna l a nd C h ild Hea lth Resea rch Institute has a n ad viso ry ca paci ty in the Mi n istry o f Health in co nnexi on with fa mil y pla nning. Am o ng the tas ks of the D epa rtment is th e coordi na tio n of fa m ily p lan ning in Po la nd. 67 coordination that has so far not had any substantial results. mainly because of the lack of specialized family planning centres within the public health service. The lack of such a specialized service does not mean that family planning is unobtainable within the public health system. but it is not particularly advertised or organized into separate units. Immediately after the Second World War family planning was provided to a much higher extent through general hospitals. and contraceptives were displayed and distributed through the hospitals. During the 1960s there was. however. a reform to the effect that contraceptives were to be purchased at pharmacies on prescription by a physician . As an unintended result of this reform the interest taken by the hospitals in family planning diminished. In the latter part of the 1970s and the early 1980s it has also been difficult because of the economic situation to maintain a steady supply of contraceptives. which are to a large extent imported from the West. In this connexion it should also be noted that physicians on the whole are not particularly well paid in Poland and that abortions and private consultations for contraceptive advice are sometimes quite important sources of income for them. A special factor in the Polish situation is the influence of the Roman Catholic Church. which is openly and actively opposed to abortion and to family planning methods other than the so-called natural methods. Some observers believe that the opposition of the Church to modern family planning sometimes leads to an increase in the abortion rate and that some women. mainly in rural areas. prefer to confess a once- only sin like abortion rather than the repeated sin of using modern family planning methods. There are . of course. no statistics to validate such a hypothesis. The recent upsurge in the activities of the Church (before the declaration of martial law on 13 December 1981) is believed by the Federation to be one of the main reasons for the newly implemented change in the abortion law . Before the change abortions were basically free and could be performed by all specialist surgeons. At present abortions can be performed only after the agreement of two physicians and by surgeons who have specialized in gynaecology. This latter requirement has. according to the Federation. reduced the number of Polish doctors allowed to perform abortions from 6000 to 4 I 00. The coordination attempted between the limited public services and those offered by the Federation has been difficult to achieve. According to the Federation the Department of Family Health does not advocate family planning as much as it should in its dealings with the Ministry of Health . nor does it utilize sufficiently the long experience of the Federation. According to the Department of Family Health. the Federation has difficulty in realizing the implications of the situation in which the Department is officially responsible and part of the government bureaucracy: although the experience of the Federation is valuable. not all family planning in Poland can be modelled on it. The major differences between these institutions can probably be traced back to the fact that the Federation is . and wishes to remain. a pressure 68 group. whereas the Department of Family Health pcrcci\'es itself as primarily a scn·icc-prm·iding institution attached to government administration . The Department of Family Health at the National Maternal a nd Child Health Resea rch In stitute not only has coordinating responsibility for family planning but also offers family planning scr\'ices directly to clients. The number of clients is limited to a few hundred for family planning and to se\-cral hundred for lectures on sex . T o this must also be added family counselling for a few hundred clients a year . The activities at the Department ha\'C not yet reached their final form: the Departm en t was institutionalized as late as th e second half of the 1970s. The family planning client s at the Department of Family Health are mainly recruited through the hospi tal s where the gynaecologists attached to th e Department work. Some family planning client s were. on the other hand . initially family counselling clients at the Department. Some family planning clients are also recruited through an anonymous counselling serv ice organized at the Department : people arc able to telephone and can recei\'C counselling ove r the telephone or later at the Department without having to give their names. Among the most important problems in this family planning clinic. as in all other clinics offe ring family planning in Poland . is the lack of contraceptives. In Poland two brands of ora l contraceptives a re manufactured under quite old licen ses. They arc both of the high dosage type and a considerable number of women cannot tak e them without serious side effects. One oral pill imported from the German Democratic Republic ha s a somewhat lower ho rmonal dose but is still not of a low dosage type. IUDs are manufactured in Poland a nd are thought to be of an excellent design . Owing to the lack of raw material s imported from the West they a re. however. at present manufactured with inferior pla stic and have been observed to break more often than they did before . Condoms are a lso manufactured in Poland . They ha ve been tested through the International Pl anned Parenthood Federation in London and it was found that mo re than 80 °0 leaked and were useless as contraceptives. Because of the economic crisis. the commercial import of contraceptives from the Wes t is at present almost imposs ible . Sex education is offered in Polish schools during the fourth year of schooling. when pupils are about 11 years old. and again when pupils are about 15 years old. This education is compulsory and integrated into biology. When the subject is touched upon for the second time , i.e. when the pupils are about 15 years old. family pla nning is mentioned . In some secondary schools sex education. organized in a somewhat different way. is given when the pupil s are about 17 years old. Participation in the education. when given. is compulsory. but it is not compulsory for schools to provide sex education at this level; the school decides whether it wishes to include sex education in the curriculum and sex education has to compete with other subjects that are similarly optional. The curriculum committee that planned sex education hoped that at least 300 schools would chose sex education. In fact. the result was considerably 69 better than ex pected . since 2000 schools chose sex educa ti on . In primary schools teaching mate rial for sex education is integrat ed into the teaching material for biology. since the subject itself is integra ted into biology. This was felt by the curriculum committee to be ad va ntageous. since the pupils would also ha ve access to the teaching material in cases where teachers were reluctant to teach sex ual matters. There is no standardized teaching material for sex education in secondary schools : the schools a re supposed to o rga nize thi s education according to the special needs of the pupil s. Schools are also supposed to invite specia list s such as physicians. psychologists. and people active in o ther ca pacities in family planning to talk about sex uality . This approach can. however. be difficult to achieve. pa rticul a rly in rural areas where the number of possible lec turers may be severely limited . Those who d o no t receive sex ed uca tio n a t seconda ry school beca use their school has chosen no t to give it have. at lea st in Warsaw. o ther poss ibilities . In Warsaw an organization for the populari za tion of sc ience ha s financed a specia l educational progra mme on six evenings eve ry year consisting of lect ures. answers to questions and film s. This progra mme had been inoperative fo r a yea r a t the time of the visit si nce no mo ney has been ava ilable for importing films from the West. The films. which were usuall y more ent ert ai ning than ed ucati onal. were used to ma ke the programme a ttrac ti ve to yo ung people . There may be a renewa l of the programme but without the films. which are believed no t to be necessary. Ed uca tio nal films on sex ua lit y are se ldom used in Po la nd a nd the curriculum committ ee had discussions with the Ministry of Education o n this: but the Ministry fo und the educa tio nal film s proposed to be too ou tspoken and even po rnographic. Sex education based on individua l counselling is a lso ofTered by the Polish Planned Parent hood Federation. This is the onl y family plan ning associa tion in Eas tern E urope that is not li nked to or sponsored by the gove rnment: it is also o ne of the very few vo luntary o rgan iza ti o ns in Poland th at does no t receive any gove rnment subsidies a t a ll. It has ofTered contraceptive serv ices for more tha n 20 years. a nd si nce 1972 spec ial counselling and therapy services as well. Two clinics ofTe r con tracepti ve serv ices. o ne in Crakow. the o ther in Warsaw. Clients pay for th e services ofTered a nd the Federation is financed through th eir fee s. There a re a lso 14 cou nse llin g cen tres . visits to which are free. In 1980. some 5000 c lients visited the co un se lling ce ntres. The stafT of the centres co nsis ts entirely of unpaid vo lunteers . To improve the financial situatio n of the Federation . as a result of a decision taken in autumn 198 1 counse lling services wi ll also ha ve to be paid for by the clients. Those who work a t the two clinics o fTer ing contracep ti ve se rvices are pa id for the ir work. The sa laries pa id by the Federation are. however. lower th a n the sa laries paid in the public hea lth secto r for co mpa rab le tas ks. The Po li sh Government se ts limit s fo r the sa la ry fo r a g ive n post. even if it is paid by a private o rga ni za tion . The Federation is also dependent o n the Government for s taffing: if it wishes to employ more people it must obtain the a pprova l o f the 70 Government. The Ministry of Health receives from the Ministry of Labour a quota allocation of new posts for the entire health sector: the Mini stry of Health must decide how this quota is to be distributed. i.e. how many physicians there will be for hospitals. how many for health centres and. if there are any left. how many for private organizations. At present the Federation has long waiting lists and cou ld well employ more physicians. but it does not consider it likely that it will be alloca ted any posts in the near future . Towarzystwo Rozwoju Rodziny (TRR}, Warsaw This W arsaw clinic is somewhat smaller than the one in Crakow. Characrer and financiny of proyrnmmc Neither fami ly planning nor sex education of particularly young people is the primary purpose of this clinic. but family planning and counselling arc also offered to you ng people. The clinic is of permanent nature and will continue its operations indefinitely. It opened as long ago as 1955 and is operated by the Polish Planned Parenthood Federation as one of thei r two family planning clinics . The general principles for the operation of the clinics are decided by the Board of the Federation . In practice the clinic is se lf-governing to a very considerable extent. Unlike the other projects s tudied . this clinic is not on ly self-supporting but also actually finances most of the operations of its national coordinating organization . the Federation. The gross turnover of the clinic in 1980 was about ZI 2 million. After all costs for salaries and equipment etc . had been paid there was a net profit of about ZI 300000. which was turned over to the Federation so that o ther activities could be financed. The income comes entirely from fees paid by clients . Personnel Everyone working at the clinic is paid for his or her services. The staff consists of two female physicians working full-time and six physicians working part-time from 3 to 9 hours a week. two male and four female . There are a lso four female nurses working full-time . A male sexologist works part-time. as does a female psychiatrist. There are also one female full-time clerk and two part-time cleaning women . In all 17 persons are employed at the clinic. There is no job rotation: members of staff have clear-cut areas of responsibility . The staff has mainly been recruited by self-selection. the majority having been working at the clinic since it started over 20 years ago. Since it is not very likely that the clinic will be allotted additional posts by the Government. the question of procedure for the recruitment of additional staff is high ly hypothetical: but it is believed that in such a case self- selec ti on would be used. those working at the clinic contacting someone they knew was interested. 71 Tary et yroups and cha rac teris tics of' clients There is no pa rti cul a r ta rget g roup: se rvices are o ffered to anyone inte rested . The client s a re pred o minantl y middle-cl ass. At least in principl e, they could have used the public hea lth system , but inte res t in fa mil y planning has dec lined in the public hea lth sec to r during recent decades. Pri va te p ractiti one rs a re a lso a n a lterna ti ve . As compa red with pri va te practiti o ners. th e Federa ti on ca n o ffer a spec iali st clinic with considerabl e ex peri e nce in a ll fi e lds rela ted to sex ualit y, including infertilit y. At the c lin ic it is believed th a t very few of the o lde r client s have had an y sex educa tio n, tho ugh some o f the yo unge r ones ha ve. Puhlici::.iny the proy ramme At the beg inning newspa pe r adve rti sements were used to make the clinic known . No ad ve rti sing has been d o ne in recent yea rs. since the c linic has as ma ny client s as it ca n se rve a nd has no poss ibilit y o f expa nding by employ ing mo re people. New client s a re ma inl y rec ruit ed by bein g to ld a bo ut the clinic by th ose who u lread y a re c li ent s. Ohstacle.1· As ca n be seen fro m T a ble 13. th e o bstacles pe rce ived to be mo re th an min o r probl ems a rc: that o the r o rga niza tio ns a nd institutio ns do no t tell po te ntial client s a bo ut the clinic: tha t the re is a consta nt ri sk o f being fo rced to c lose due to lac k of mo ney: tha t continuing training of pe rsonnel is lackin g: and tha t equipment and supplies are lacking. Since the clinic ma kes a ha nd some pro fit it seems odd tha t the sta ff of the clinic sho uld be wo rried a bo ut m oney: o ther represent a tives of the ' Federati o n do no t sha re tha t co nce rn . The mos t import a nt obstacle a t present is lac k of mode rn cont racepti ves, the result o f the present situ a tio n in Po land . In a utumn 198 1 the c linic rece ived some suppli es fro m the Inte rna ti o na l Planned Pa renth ood Fede rati on . So me additio nal supplies were a lso recen tly sent fro m Swede n. The cont racepti ve ad vice give n to cli ent s is obv io usly affec ted by the lac k o f adequa te cont race pt ivcs. Possihll' t lw 111es and ta rye ts All groups except preschool children a nd children a t prima ry sch oo l a re ra ted as impo rt a nt o r ve ry impo rt a nt ta rgets fo r sex educa ti on . Th e ratings o f ta rge t gro ups fo r fa mi ly pl a nnin g sho w th a t a ll the gro ups a re conside red to be impo rt ant o r ve ry impo rtant as ta rge ts for fa mil y pl a nning se rvices. U nlike m os t of the other p rog ramm es s tudi ed , thi s o ne places no specia l emph as is on yo ung peopl e. Yo un g peopl e a re we lcome but a re no t th o ught to be mo re impo rt a nt th a n o the r gro ups. N 11111her of clients. Sl' rr icl's yin'n . and .f1'es In 1980 some 10 boys . 1500 girl s. a nd 4500 adult s we re seen a t the clinic. Sex educa ti o n and cont race pti ve se rvices we re give n to 4 boys and 1500 girl s. 72 Table 13. TA R Warsaw: rating of possible obstacles Indication Possible obstacle of importance8 Potential clients have too vague an idea about family planning 3 Potential clients are hostile to family planning 1 Potential clients are hostile to sex education 1 Parents of potential clients object to family planning for you ng people 3 Parents of potential clients object to sex education for young people General traditional values in society I I literacy The uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme/ project centre makes it difficult to reach 3 Business hours of the programme/ project make it difficult for potential clients to get in touch Other organizations/institutions do not tell potential clients about project 4 Constant risk of being forced to close due to lack of money 4 Constant risk of being closed down due to lack of pol i- tical support Lack of specialist personnel 1 Lack of voluntary workers 1 Lack of continued training of personnel 4 Problems of cooperation among staff 1 Lack of clearly understood objective 1 Lack of clearly defined target group 3 Lack of equipment 5 • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem . There is considerable confusion about the contraceptives advised or prescribed . During the visit one set of figures was presented . Later the physician heading the clinic supplied figures for contraceptives advised or prescribed that completely contradict those received at the clinic: Condoms Spermicides Diaphragms IUDs Ora l contraceptives Long-acting injectable contraceptives Coitus interruptus Swdr risit 0 01) 0 oo 77 °,, 5 0 0 15 °,, 0 00 3 0 (I Reply to questionnaire 40 °,, IO 0 ,, 7 0 0 4.5 °,, 4 00 0 00 35 .5 °,, 73 The probable explanation for the differences is the present great shortage in supplies of contraceptives. which inevitably affects the advice given. It is reasonable to assume that the left-hand column indicates the advice or prescriptions given when sufficient supplies are available. The right-hand column probably describes the present situation: supplies of diaphragms are uncertain. low-dosage oral contraceptives are almost impossible to find . the IUDs available can be dangerous . and condorr,~ are available but are known to be unreliable . The use of unreliable condoms is probably preferred to the use of no condoms at all. The clinic is open from Monday to Friday from 8.00 to 18.00. All the services. except those of the sexologist and the psychiatrist. are available all the time . The sexologist and the psychiatrist work for six hours a week each. Clients can either phone for an appointment . which is usually given on the same day. or show up in the morning and wait. usually not for more than three hours . The client is first met by a receptionist. who fills in the necessary forms and records the basic data. The client then sees a physician for the consultation and later a nurse. who gives what instruction is necessary . The fee the client pays varies with the service demanded . An ordinary consultation costs ZI 150. including prescription of a contraceptive other than an IUD. The cost for an IUD insertion is ZI 300. plus the cost of the IUD. which varies from ZI 240 to 400. The fee for a discussion with the sexologist is ZI 200. There are no special reductions for young people ; everyone pays the same amount for the same service. Department of Family Health, National Maternal and Child Health Research Institute, Warsaw The Department of Family Health at the National Maternal and Child Health Research Institute has a dual position with regard to family planning. On the one hand it has coordinating responsibility for family planning in Poland in connexion with its advisory capacity to the Ministry of Health. On the other hand it also runs a rather small family planning clinic of its own. The Department is still (late I 981) in the process of formation. Its present tasks were allotted to it only in 1978. Character and fi11a11ci11y of" proyramme The Department of Family Health is one of 17 research departments of the Institute. which also has 12 clinical departments. Its main function is the provision of services. research. teaching. and integration and coordination of MCH services at the national level. The services offered are all labelled as family counselling and consist of family planning and psychosocial counselling and therapy. Research and research coordination at the Department are concerned with the methodology of family counselling and of health education and the effectiveness of family planning methods. The teaching activities 74 consist of the training of paediatricians for specialty examinations and of family counsellors and the organization of international courses in collaboration with WHO. Since the Department is a government institution it is totally financed by the Government: clients do not pay any fees. since their participation is considered to be part of the research. In 1981 the total cost for the Department of Family Health was ZI 2 467 669. Personnel Everyone working at the Department is paid for the work done. There is no job rotation. but the clients are usually seen by a team of specia li sts who work together. At present seven persons are employed at the Department. It s head is a fema le paediatrician, and she is assisted by a female gynaecologist, a female psychiatrist. a male educator. a female psychologist, a female therapist, and a female social worker. They a re all, except the gynaecologist, employed full-time at the Department. The gynaecologist works 50 hours a month . At the Department it is believed that two more persons, a sexologist and a legal adviser, could be employed in the near future . Although the stafT is formally recruited by public advertisement followed by selection among candidates by a recruitment committee, in reality the recruitment procedure can be described as self-selection. since those setting up the Department initially selected the first of the employees. who later participated in the selection of the rest of the staff Taryet yroups and characteristics of' clients People under 30 years of age are considered a major target; about 60 °0 of the clients are below that age. C lients could go elsewhere for the family planning services ofTered. At the Department it is believed that clients come to them because of the more comprehensive services ofTered: the Department is able to ofTer not only contraceptive services but also psychosocial therapy. It is believed at the Department that very few of the clients have had any previous sex education . Puh!ici::.iny the proyrnmme The method used to inform the public about the Department has been contact with the mass media and with other branches of the public health service . Some clients are also recruited through the anonymous counselling available: it is possible for people to phone the Department and discuss their problems without disclosing their identity . Following the telephone contact they can come to the clinic and receive therapy and family planning services. still without revealing their identity. The majority of those who are recruited in this way do. however, disclose their identity at some stage of therapy. This anonymous counselling is advertised in the mass media. Anonymous counselling. in combination with the research reputation of the Department. has led to 30 °0 of the 75 clients coming from places other than Warsaw. The recruitment of new clients is also facilitated by the recommend- ations of families who have obtained help at the Department. Ohs tac/cs As can be seen from Table 14. very few of the possible obstacles listed are problems for the Department. Only two were een to cause at least some problems: potential clients have too vague an idea of what family planning is . and eq ui pment is lacking. by which is meant a lack of Table 14. Department of Family Health, National Maternal and Child Health Research Institute, Warsaw: rating of possible obstacles Possible obstacle Potential clients have too vague an idea about family planning Potential clients are hostile to family planning Potential clients are hostile to sex education Parents of potential clients object to family planning for young people Parents of potential clients object to sex education for young people General traditional values in society Illiteracy The uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme / project centre makes it difficult to reach Business hours of the programme/ project may make it dif - ficult for potential clients to get in touch Other organizations / institutions do not tell potential clients about project Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of poli - tical support Lack of specialist personnel Lack of voluntary workers Lack of continued training of personnel Problems of cooperation among staff Lack of clearly understood objective Lack of clearly defined target group Lack of equipment • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem . 76 Indication of importance• 4 2 1 1 2 1 1 1 1 1 1 3 contraceptives. The available supplies of all contraceptives are limited and many are totally lacking. Other obstacles mentioned in the Department of Family Health were paper shortages. printing difficulties. lack of funds for questionnaire studies. and a limited possibilit y of employing a sufficiently large staff. Possihle themes and tarycts At the Department of Family Health only six of the sex education th emes li sted were considered to be important or very important: sex roles: parenthood : love: psychology of puberty: contraceptives: and abortion. Intra-family relation ships were added to the li st. All the groups li sted were rated as eq ually important. i.e. very important. in relation to sex education. and all as very important in relation to family planning with the excep ti on of young gi rl s as soon as possible after the menarche a nd of yo ung boys as soon as possible after the first emission of semen . Numhcr of' clients, scrrices yiren. and fees In 1980 some 85 girls and 400 ad ult s received contraceptive se rvices a t the Department. The staff of the Department give lectures on sexuality in schools and other institutions when asked to do so: about 600 young people were lectured to in 1980. About 150 girls also received ot her gynaecological or medical services. No detailed figures were available for the contraceptives advised or prescribed . The contraceptives most often used for yo ung girls are, however. oral contraceptives and IUDs. Diaphragms are sometimes used and natural methods sometimes recommended. Clients come to the Department through referral from some other institution. through the anonymous counselling sys tem . or through approaching the clinic directly. about which they have been told by friends . At the Department a non-clinical atmosphere is sought. through the abolition of white clothing for the staff and the use of titles . The furniture is also more that of a living-room than of a hospital. Clients do not pay fees for the services rendered . Portugal In Portugal three very important bodies are concerned with family planning. I . The Minist ry for Social Affairs. which has three sec retaries of state. two of them involved in family planning: the Secretary of State for Health and the Secretary of State for Family Affairs . The Directorate- General of Hea lth is under the Ministry of Social Affairs. 2. The Commission on the Status of Women. which is attached directly to the office of the President of Counsel. 77 3. The Family Planning Association (Associac;ao para o Planeamento da Familia. APF). In Portugal discussions were held at the Ministry for Social Affairs. and visits were arranged by the Ministry to three health cen- tres in Lisbon and to the hospital Santo Antonio in Oporto. A study visit was also made outside the official programme to the APF branch of Lisbon and discussions were held with the APF. Portugal. Discussions were a lso held with a research project supported by WHO and the National School of Health. The Portuguese Commission on the Status of Women uses the media for a number of activities that reach adolescents . It has prepared a TV programme on adolescents and contraception . and in I 980 a radio spot aimed at adolescents was broadcast. Short articles on the benefits of family planning for young people have been published in women's magazines. University students in Lisbon. Oporto and Coimbra are reached through its medical services. Thousands of brochures and leaflets have been distributed to young people. Young people ' s cultural cen tres. 30 in a ll . have asked the Commission for large amounts of educationa l material on family planning. According to figures quoted by the Directorate-General of Health. 157 health centres at present offer family planning services. It is estimated that about 5 ° 0 of the women in the reproductive period use some kind of family planning. including natural methods . It is the aim of the Directorate-General of Health to increase this figure to IO 0 ., within the next few years. The Directorate-General of Health issued a circular in August I 98 1 to a ll staff at health centres forbidding minors (i.e . those below 18 years of age o r. in very spec ia l cases where the person in question has been "emancipated". below 16) access to family planning clinics without previous parental consent. The grounds for this restriction is that the counselling of minors in family planning clinics without such permission could be an infringement on parental rights . This regulation has greatly troub led people active in family planning trying to provide services for young people. and the Commission on the Status of Women has requested the Government to review the situation. In some cases services are sti ll provided to young people by a very literal interpretation of the new regulation: young people are not seen in the family planning clinic but in the health clinic . i.e. in another part of the same premises. On the other hand overinterpretation of the circular also exists: at one health centre the regulation had been interpreted to forbid not only family planning to young people but also sex education in family planning clinics . The Ministry for Social Affairs was aware of the debate the regulation had caused. but stressed the importance of parental rights in general and in fami ly planning matters in particular. The oflice of the Secretary of State for Family Affairs expressed an interest in sex education for young people. but held that such education should preferably take place within the family . It was said that earlier experience of sex education 78 immediately after the revolution in 1974 had been disturbing: there had been excesses that some people at the Ministry labelled as pornographic. A visit was made to the health centre at Domingos Barreiros . which is de;)endent on Santa Casa da Misericordia de Lisboa. a voluntary religious organization. Unlike most health centres. those attached to the Santa Casa da Misericordia de Lisboa are not organized under the Directorate-General of Health but are supervised by the Secretary of State for Family Affairs . Funds come mainly from a state lottery. The health centre visited offers MCH services. including some family planning. and also trains family therapists. It serves a residential area with about 25 000 inhabitants . Social workers organize free-time activities for the inhabitants. among them educational groups for adolescents. In the past year two groups (40 adolescents altogether) received sex education. a physician attached to the centre talking for a few hours to the adolescents about sexual matters . The physician said that family planning and contraceptives were not mentioned unless the adolescents asked about them . In I 981 rather more than I 00 women asked for family planning services at the centre . When a woman asks for family planning she is asked to return along with her partner. The staff of the centre tell the couple about available methods and leave the choice entirely to the couple. According to what was said during the visit about half of the couples then choose not to have any family planning method at all: 58 women did. however. during 1981 opt for family planning. Of these 58. 10 preferred natural methods. which are given special emphasis at the centre. The impression at the centre was that the IO who had chosen natural methods were mainly younger. As far as the staff of the centre knew. family planning had worked satisfactorily for those couples during 1981. Since there is a special emphasis on natural methods. the staff of the centre take pride in explaining them in detail and hope that they will be as effective as other methods when the couple has been given a thorough education. In 1976 family planning at health centres became legal in Portugal. This health centre did not. however. start family planning counselling until 1979. the reason given being that it wished to prepare the staff properly and educate them thoroughly in natural methods before offering any family planning. There is no special family planning for young people at the health centre and sex education for young people is limited to what is included in the educational groups referred to above. A visit was also made to a health centre in Lisbon that is organized under the Directorate-General of Health. The health centre. called Sofia Abecasses . is quite small and caters for about 15 000 inhabitants. It is . however. unusually well staffed, with IO full-time nurses and 12 part-time physicians (equalling about 5 full-time physicians) . Because of the interest of the staff impressive statistical records are kept. each street and every house being indexed with accompanying notes on diseases and the action taken . Infectious diseases are plotted on maps. Detailed records 79 are kept on illiteracy and the use of family planning. As a part of the official programme, a visit was also arranged to the hospital of Santo Antonio in Oporto. In Oporto family planning and sex education activities are strengthened by the cooperation between the Santo Antonio Hospital hea lth centres and the Family Planning Association (APF). This cooperation is made possible particularly through the interest in family planning of one physician in particular at the Santo Antonio Hospital who is also active in the APF. Being a former Secretary of State for Health and active within one of the present government parties, he is able to exert an influence that could be decisive in the building up of effective family planning services for young people. This physician has also recently. on behalf of the Directorate-General of Hospitalsr applied to UNFPA for the funding of a family planning project that includes, inter alia. two pilot family planning clinics for teenagers. No such clinics exist at present in Portugal, although in the Santo Antonio Hospital in Oporto teenagers are seen and their attendance at the family planning clinic is facilitated by. for instance. the giving of appointments to them much sooner than the waiting list would normally permit. The APF in Oporto. in collaboration with physicians from the Santo Antonio Hospital and other hospitals. also tries to motivate young people to use family planning. In relation to motivation to use family planning. it was pointed out to the consultant that the influence of Portuguese migrant workers to Northern Europe is most important. When they return home they have often learned to employ family planning techniques during their stay in Northern Europe. Information leaflets on family planning produced in the Federal Republic of Germany by the Planned Parenthood Federation (Pro Familia) in the Portuguese language are also circulated by returning ..yorkers. During his stay in Portugal the writer had discussions with a research worker at the Escola Nacional de Saude Publica and collaborators in a study of growth. sexual development. and sexuality in adolescents. a study sponsored by WHO. One of the aims of this study is to collect data in order to propose programmes dealing with sexually related matters and . possibly. for use in the training of teachers and health professionals. It is also the purpose of the research project to supply data that could be used by primary health care providers in offering services to adolescents . Associa~ao para o Planeamento da Fami lia (APF), Lisbon Clwral'fer and fi11a11ci11y of proyrnmme Neither family planning nor the sex education of young people is the primary aim. although the association does provide sex education to young people and tries to motivate them to use family planning. Family planning services are. however. not offered and medical examinations not performed. An important reason for this is that. according to the APF. the national health system should be responsible for health services like 80 family planning. The maJor objectives are thus education and motivation. The Lisbon branch is on a permanent footing and will continue its activities indefinitely if it has sufficient funds. The total cost in 1981 for the Lisbon branch was Esc . 320 000. Costs are 80 '/0 covered by grants from UNFPA. 10 ° 0 by the national AFP. and 10° 0 by the Lisbon branch itself. Perso1111el The Lisbon branch of the APF. like the APF as a whole. relies almost entirely on volun tary work. Those who do voluntary work could. however. equally well have been professionals or clerks if sufficient funds had been available. At present only two persons. a sociologist (male) and a chemist (female). are employed by the Lisbon branch. Voluntary workers devoting a considerable amount of time to work with the organization are a male psychiatrist. a female psychologist. a female nurse. a male health teacher. a male and a female teacher, and two other fe males hold ing the title of "generalist". Where it is found possible people are encouraged to work in more than one area and job rotation is practised when it does not interfere with the specialist skill needed for some tasks . People working with the Lisbon branch have been selected by self- selection. but the voluntary organizations board has to approve of people selected. Target groups and characteristics of clients As far as young people are concerned. activities are primarily directed to the age bracket 14- 18 years. About 80° 11 of those who have participated in the specia l educational groups organized by the Lisbon branch have come within that age bracket. Since 1980 two special educational courses have been organized: one for a group of young people in the Charquinho area. the o ther for students from several high schools in Lisbon . Almost none of the participants had had any previous sex education. T hese courses were only a part of the activities of the Lisbon branch of the APF. Most of the work carried out was community work, mainly m two areas. Charquinho Bairro and Fontainhas Bairro . This community work covered not only youth groups but also groups of women and groups for family planning. A number of contacts with the a uthori ti es were made in order to advance family planning projects in these areas. The ado lescents who participated in the sex education courses could probably not have gone elsewhere, since sex education is not given in schools and no other organizations are particularly active in this field . The on ly ot her source of sex education seems to be what is given by physicians during private consultations or by physicians or other health professionals, as in the health centre at Domingos Barreiros. Puh/ici::ing the programme In general, those who work with the Lisbon branch of the APF get in 81 touch with other community workers or are approached by people working within community projects who perceive the need for education on family planning. In one of the two residential areas where the APF has been active the initial contacts seem to have been established by the APF. whereas in the other the APF was approached by a group of Dominican missionaries working with people from Cape Verde. Adolescents joining the special educational groups for young people were recruited through contact s with parents as well as with teachers and with the young people themselves during the initial stages of community work . Major obstacles when trying to give publicity to the existence of educational facilities for young people have been lack of money and lack of access to the target group. Since youth organizations are scarce or absent in high schools and in local communities it has been difficult to find entry points into the world of adolescents . Ohs tac/es As can be seen from Table 15. the chief obstacles are: that parents of potential clients object to family planning for young people: that family planning is contrary to traditional values: that it is not socially recognized that young people have intercourse: that the opening hours of the branch make it difficult for potential clients to get into touch: that there is a constant risk of being forced to close due to lack of money: and that specialist personnel and voluntary workers are in short supply . Of these obstacles the three seen as serious are traditional values. social refusal to recognize that young people have intercourse: and the lack of money. Some of the obstacles were anticipated. others were not. such as the lack of money and the lack of continued training for the personnel. The latter is. however. not perceived as an important problem. Government help was requested in connexion with the lack of money and the lack of continued training. but so far it has not been received. Discussions are also being held with UNFPA on funding and with WHO on training. In connexion with the lack of access to the target group. contacts with teachers and schools have been intensified. Possihle themes a11d 1arye1s Only three themes for sex education are not rated as very important: the religious view of marriage and the family. pornography. and sterilization . An additional theme. prostitution. not included in the original list. is considered important by the Lisbon branch . In relation to the importance of reaching various groups with sex education . only three groups were not seen as important or very important : pre-school children . women with many children . and men with many children . It was considered important or very important to reach all groups with family planning. Numher of" clie111s . serrices prorided , and f ees The two sex education groups referred to earlier consisted of about 60 boys and 90 girls altogether. The Lisbon branch also participated to 82 Table 15. APF Lisbon : rating of possible obstacles Possible obstacle Potential clients have too vague an idea about family planning Potential clients are hostile to fam ily planning Potential clients are hostile to sex education Parents of potential clients object to family planning for young people Parents of potential clients object to sex education for young people General traditional values in society Illiteracy The uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme/project centre makes it difficult to reach Business hours of the programme/project make it difficult for potential clients to get in touch Other organizations/institutions do not tell potential clients about project Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of pol itical support Lack of specialist personnel Lack of voluntary workers Lack of continued training of personnel Problems of cooperation among staff Lack of clearly understood objective Lack of clearly defined target group Lack of equipment • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem. Indication of Importance• 4 3 5 1 1 5 4 1 5 1 4 4 3 1 3 3 3 some extent in community work o rga nized by o thers a nd in tha t way reached a n additi ona l 70 ado lescents. All rece ived sex educa tio n. and about 20 boys and 40 girl s a lso rece ived counse lling. Th ere a re no fees for the educa tio na l a nd counselling services o ffered . Medica l a nd cont race pti ve se rvices a re no t o ffered . If. however, someone needs a prescriptio n o r a n exa mina tio n in connexio n with fa mil y planning the b ra nch refers the person to someone who can suppl y contraceptives a nd ma kes sure th at the client rece ives a n appo intment within a few days . A det a il ed desc ription of the ac ti vi ties of the Lisbo n b ra nch of the APF. together with a n eva lu atio n of those ac tivities. has recentl y been issued as a document. It covers the orga niza tion of comm unit y wo rk in 83 the different residential areas and presents the clients' evaluation of their experience. Sweden Youth Advisory Clinic, Stockholm School Board In Sweden special youth clinics offering contraceptive se rvices have existed since the early 1970s. Befo re that family planning se rvices were arnilable for yo ung people mainl y through hospitals and through the family planning association (RFSU). Alth ough existing in many places. special youth clinics arc not available all over the country. All the existing clinics have grown o ut of local initiati ve. Sometimes they are organi7ed within the public health system. sometimes as part of the soc ial welfare system. sometimes as a part of the school health system. Some offer a whole range of social and medical services. others only gynaecological and contraceptive se rvices. A study visit was made to Ungdomsmottagningen vid Stockholms Skolor. the youth advisory clinic of the Stockholm School Board. It started in 1970 and at that time was called the adviso ry agency for sex and cohabitation of Stockholm's schools. The clinic is one of the biggest youth clinics in Sweden . Characrer and financiny of proyramme Sex education of young people is stated to be the primary task of the clinic. It also. however. offers family planning and counselling for young people. Administratively the clinic is part of the school administration of the municipality of Stockholm. The staff employed at the clinic are employees of the Stockholm School Board . Guidelines for operations were drafted in 1970 by the senior school physician in Stockholm. The School Board discusses with the clinic fund ing and such developments as the creation of new posts. The total cost for the clinic in 1981 was estimated at S.kr.678000. of which S.kr. 618 000 went to salaries. The clinic is funded entirely by the School Board in Stockholm. No volunteers participate . Everyone working with the project is employed by the School Board . Personnel Eight persons are employed. No one works full-time. The staff consists of one female gynaecologist working 20 hours a week, three midwives each working 20 hours a week , one female psychologist working 20 hours a week , one male psychiatrist working eight hours a week, a nd two female receptionists each working 20 hours a week. Midwives in Sweden , when specially trained , are allowed to prescribe oral contracep- tives and insert IUDs. People working in the project were appointed after public advertise- 84 ment of vacant posts. This procedure has been affected by some elements of se lf-selection . since known poss ible candidates ha,c been urged to apply for the , aca nt posts. Tar!Jl'I yroups and charac1nis1ics o( c/ie111s The target group consists of pupils in the schoo ls of Stockholm . Some young people . i.e. those who do not continue in sc hool. arc allowed to , isit the clinic for two yea rs after they have finished compulsory sc hool. In Sweden about 80 °., of the pupils conti nue schooli ng after the compulsory period. The clients co uld go clsc\\herc for family planning and sex education - to the family planning association (RFSU). to family planning clinics within the public health system. and to the adolescent clinic operated by the Church of Sweden . \\hich also offers contraceptive services. That their clients go to the clinic instead of to other service-provid in g organizations is thought to be the result of the contacts the clinic mak es when giving sex education in the schools and to the fact that it is a part of the schoo l health system. so that school nurses tend to refer yo ung people to it . C lients arc usually between 12 and 20 years of age . Almost all the client!-. have had ~ex education . It is. however. often said by the yo ung them se hes that the education they have received is not adequate. The impression of the staff is that all social groups are represented among their clients. a lthough young people with social problems a re under-represented and , cry few of the clients a re immigrants. P11hlici::i11y !he proyr1111mIl' The clinic makes itself known th rough information given to teachers and school nurses as well as through pamphlets distributed in schools. It is estimated at the clinic that about 20 ° 0 of the girls in the Stockholm school s know about the clinic. whereas a lmos t none of the boys are awa re of its existence. The most important fac to rs in the recruitment of new clients are the recommendations of former clients and referrals by school nurses. The clinic has no t encounte red problems in trying to make itself kn own. Ohs1ac /es As can be seen from Table 16. none of the possible obstac les listed was rated as an important problem. It was. however . mentioned that those who work half-time would prefer to work full-time . Possihle !hemes and 1arge1s Only two of the possible themes for sex education lis ted were not rated as very important : the religious view of marriage and the family was rated as of some importance only and sterilization was rated as of no 85 Table 16. Youth Advisory Clinic, Stockholm School Board : rating of possible obstacles Possible obstacle Potential clients have too vague an idea about family planning Potential clients are hostile to family planning Potential clients are hosti le to sex education Parents of potential clients object to family planning for young people Parents of potential clients object to sex education for young people General traditional values in society Illiteracy The uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme/project centre makes it difficult to reach Business hours of the programme/project make it difficult for potential clients to get in touch Other organizations/ institutions do not tell potential clients about project Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of political support lack of specialist personnel Lack of voluntary workers Lack of continued training of personnel Problems of cooperation among staff Lack of clearly understood objective Lack of clearly defined target group Lack of equipment • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem Indication of importance • 3 3 2 2 1 3 2 missing 3 2 missing 1 1 importance at all. Three themes were added since they were not included in the list but were felt to be important: incest. prostitution. and rape. Groups rated to be very important as targets for sex ed ucation were: children at primary school: children at secondary school: ado lescent girls: and adolescent boys . These groups were all included in the target. As regards possible target groups for family planning. only young gir ls as soon as possible after the menarche and young boys as soon as possible after the first emission of seme n were given some importance. They were both included in the target. Numha o( clients. serrices 11ire11. and Ji•es In 1980. 213 boys and 270 1 girls were seen at the clinic. and among 86 them 2 1 boys and 270 girls .,,,-ere given sex education . Contraccpti\'c services were offered to 21 boys and 1500 girls . other gynaecological and or medical services to 149 boys and 540 girls . Counselling and therapy were given to 17 boys and 270 girls. counselling in connexion with abortion to 5 boys and 135 girls . Of those receiving contraceptive services about 80 "., were given oral contraceptives: most of the others were recommended to use condom s. Diaphragms and IUDs were provided in exceptional cases only . There are no fees . Clients can either telephone for an appointment or. if they already are clients. attend during certain open house hours for which no previous appointment is necessary . The first time the patient comes to the clinic he or she has. however. to make an appointment in advance . Each client is seen for at least half an hour and has an opportunity for discussion with a staff member and for an examination. Yugoslavia In Yugoslavia discussions were held at the Family Planning Council in the autonomous province of Vojvodina and at the University Hospital in Novi Sad. also in Vojvodina. Study visits were made to an educational programme in the Republic of Montenegro and to the Reproduction Unit (previously the Family Planning Institute) of the gynaecological department at the University Hospital. Ljubljana . Yugoslav practices in relation to family planning and fertility regulation differ somewhat from those in the other countries studied . Abortion is practised much more frequently. Irrespective of the legal situation. abortion has long been important for fertility regulation . not only in Yugoslavia but also in other countries in this part of the European Region . In Yugoslavia the number of abortions increased rapidly from 1946 to 1948 . In 1948 abortion was made legal. and in 1952 a new law was introduced giving detailed indications for abortion: the emphasis was on medical indications. although it was possible to obtain a legal abortion for social reasons. The importance of social reasons grew. and in 1960 a new and very liberal abortion law was introduced . At the same time it was stressed that contraception was to be preferred and that abortion should be used only as a last resort. According to the Yugoslav constitution (article 191) "It is a human right to decide freely on childbirth. This right may be restricted only for reasons of health". In 1977 the present legislation was introduced in all the republics and provinces; since Yugoslavia is a federation, the exact phrasing of the law varies from republic to republic . The basically liberal attitude to abortion is. however, present in all the republics. The laws of Slovenia and Croatia are almost identical in these matters and, unlike the laws of the other republics, include a section on sterilization. The comprehensive family planning legislation contains chapters on sterilization (only in Slovenia and Croatia), termination of pregnancy, contraception, and subfertility. 87 The population in Slovenia and Croatia are predominantly Roman Catholic, whereas most of the population in the other republics are Serbian Orthodox. The influence of the church is, howeve r. minimal in family pla nning ma tter . The Roma n Catholic bishops in Yugoslavia have issued a s tat ement against abortion and the magazine of the Catholic church regu la rl y makes it clear that the church does not a pprove of any family planning meth od s other th an na tural ones. Nei the r the Roma n Catholic church nor the Se rbian Orthod ox church seems. however. to be ab le to influence the choice of the population in Yugoslavia to any substan ti a l ex tent. Family planning is widespread and . where it is not practised, thi s is usually not due to the influence of religion . Abo rti on is usualfy free up to the ten th week (with minor diffe rences ex isting between the republics) . It is usua lly performed on a n ambula tory patient and by the suction method. In some provinces abortions a re no t registered centra ll y and it is therefore imposs ible to know exac tly how many a borti o ns a woman has had . In all the places visited exceptional cases were known where women had had mo re than 20 abortions. Since abortion is used as a fertility-regulating measure the demand is great. This ha s led to a heavy workload for gy naeco logists, who sometimes do 30 abortio ns before lunch . Abortion clinics are very efficient and medical complica tio ns few. The efficiency of the abortion cli nics in handling large numbers of women in a sho rt time has led to the exis tence of illegal abortions in a country where abortions are free. Some wome n arc willing to pay a physician fo r performing a n abortion privately in somewhat more pleasan t cond iti ons than those offered at the aborti on clinic. Since private medical ca re is no t al lowed in Yugoslavia such ahortions arc illegal. Vojvodina Autonomous Province The province of Yojvodina . wi th abou t two milli on inhabitants of all the Yugoslav nationalities. is mainly agricultural. Fertility rates have always been low in Yojvodina. the fami lies typically having o nl y one child . People emigrating from ot her republics to Yojvodina have rap idly adop ted th is pattern and the province is faci ng a dec line in population . The severe housing shortage. wi th you ng coupl es experienci ng difficult y in finding ho uses of their own. probably also contributes to th e prefe rence for small families . Some obse rve rs are inclined to believe th a t the falling population will lead the a uth o rities to ado pt an attitude favo urin g a higher hirth ra te rather than the one held at present. acco rding to which fa mil y planning is a constitutional right and the size of the families is decided by the families themselves without interference by the Government. Family Pla1111i11~1 Co1111 cil. I ·ojrodina The Family Plannin g Counc il is o ne of 30 councils elected by the Socialist Alliance. The function of the Council is to make recommendation s to the 88 local government within its sphere of competence, and of its experts to initiate proposals for activities as well as for new legislation. The Council has 20 members elected for two years. people within the professions relevant to the sphere of authority of the Council. In the Family Planning Council there are sociologists, psychologists, lawyers, and physicians. The members are elected within each professional group and members cannot be re-elected after they have served on the Council. As the number of persons interested in family planning is limited, it often happens that a person serves on the Council for two years. another person serves for two years, and the first person comes back for another two years. The Family Planning Council is responsible for sex education out not for contraceptive services. which are under the Health Council. In Yugoslavia sex education is called humanization of the relations between the sexes. The education given includes not only biology but also sex roles and other aspects of the relation between the sexes. It is integrated into the curricula of the regular subjects taught at school and is not a subject taught in itself. In connexion with this education the Family Planning Council organizes special seminars for teachers. where they are trained to integrate sexually related themes into their teaching. The programme of the Council in Yojvodina in 1981 was the following. - In connexion with the forthcoming revision of school curricula, the humanization of the relations between the sexes was to be integrated into more subjects and more levels . - The importance of social workers in family planning was to be studied. with the aim of utilizing the services of social workers more often. - Symposia for health personnel on the health aspects of family planning were to be arranged. - The proposed legal changes in health care. child care. and parental rights and duties were to be evaluated. - A project was to be launched aiming at intensifying family planning propaganda so that the papers published in Yojvodina contained a full page on family planning at least once a week. When asked about obstacles. the Council pointed out that not all professional groups realized that they could contribute to family planning. Social workers and pharmacists. for instance. did not always realize that they possessed knowledge that could be transmitted to their clients and customers so that they were informed about family planning even when the clients did not raise the subject themselves . It also believed that some physicians did not fully realize the importance of promoting family planning. and hence only provided contraceptives when asked to do so instead of ofTering contraceptive se rvices to their patient s. Unirersity Hospital . Nori Sad The family planning department at the university hospital has special opening hours for young people- three hours twice a week. Young 89 people can also attend during the regular opening hours . It ha s been estimated that about 10- 15 °0 of adolescent s show up outside the special times set aside for them. This, at least partly , is the result of mothers bringing their daughters with them for gynaecological examination by the gynaecologist the mother usually goes to. This is often the case when the girl goes to have her first gynaecological examination. The practice, however, does not imply that the mothers bring their daughters to the clinic for contraceptive supplies, but rather for other gynaecological consultations. In Yugoslavia it is legal to provide contraceptive services to and perform abortions on an adolescent of 16 years. If the adolescent is between 14 and 16 years old the permission of a parent is required. Such permission , according to experience at the hospital, is never refused to teenagers who wish to terminate a pregnancy. The problem is rather that very young girls sometimes insis t on hav ing the baby . At the hospital great scepticism was d isplayed about prescribing oral contraceptives for very young girls or inserting IUDs. The preference was very much in favour of condoms. The very liberal abortion practice and the lack of stigma attached to abortion makes abortion a much more realistic alternative for the very young. In most other countries a bortion is considered more undesirable than hormonal intervention , even during puberty. When young girls ask for contraceptive advice it is first recommended that their boy friends should use condoms. Diaphragms are not readily available and IUDs are considered less suitable for the very young. If a young girl insists , however , oral pills are prescribed. In 1980 more than I 000 young girls received contraceptive advice at the family planning department. It was felt that these young girls lacked knowledge not only about reproduction and conception but also about sex ually transmitted diseases . According to a study on contraceptive practices conducted in Novi Sad by Dr Nila Kapor-Stanulovic in the mid- I 970s, the most often used family planning method is coitus interruptus. The second commonest method is the condom, the third oral pills. Considering that modern contraceptives are easily available free of charge or at very low cost, this may be somewhat surprising. It was interpreted as being the result of a tradition where family planning is perceived as being mainly the responsibility of the male . Yugoslavia has a long patriarchal tradition and, in spite of its efforts to strengthen the position of women , it is still often true that the number of children in a family is decided upon primarily by the man . Since little or no social stigma is attached to abortion, women in many cases seem to leave contraception to the man and rely on abortion when contraception fails. Republ ic of Montenegro Discussions were held at the local hospital in iksic in Montenegro. The hospital se rves an area with a population of about 80 000. Between 20 000 and 24 000 women in the reproducti ve age are found in the district. 90 Contraceptive services are offered by the family planning clinic at the hospital and in connexion with all births at the hospital. Mothers usually spend seven days at the hospital in connexion with a delivery; for one hour on each of these days they receive health education, including family p lanning education. At the family planning clinic there were 3500 clients in 1980, very few of them (less than I 00) under 20 years old . Although all the clients received rontraceptive advice. they did not all use modern contraceptives. Many women said that their husbands were opposed to the IUD. Since communication on sexual matters is difficult between the partners, the women seldom knew what exactly the men objected to . Many women were also reluctant to choose oral contraceptives since they did not believe they would manage to take them regularly. Diaphragms had been used earlier. but supplies were uncertain and sanitary conditions did not always make them suitable. Spermicides can be easily bought at pharmacists and were probably used quite often. At the hospital , however, they were considered less reliable. At the hospital the first suggestion was usually the IUD. In spite of this. of those who used any method that required a prescription about 60 °0 used oral pills as against 40 °0 for IUDs. In 1980 the number of abortions registered at the hospital was 581, of which only seven or eight were performed on women under 20 years of age. The number of young mothers was also low. with only one or two girls under the age of 16. There were no abortions performed on girls as young as that. This was believed to be a result not of effective contraceptive use but rather of low sexual activity. Asked about the main difficulties in work on family planning. the first thing the clinic mentioned was the workload: at the hospital there are 1300 births every year and only six physicians are available. They should not only take care of deliveries but should also provide family planning services. Humani::ation ol the relations het1l'een the sexes , Montenegro The purpose of this project is integration of the subject of humanization of the relations between the sexes into the teaching of all subjects at all school levels in Montenegro . Humanization of the relations between the sexes is not only a euphemism for sex education: sex education is indeed included in its narrow form as a subject incorporated into the teaching of biology. But the purpose of the project is much broader. Humanization of the relations between the sexes in. for instance. literature is meant to create awareness of sex-based stereotypes and of sex roles. Working with the project are about 25 specialists from fields as different as sociology. philosophy. literature. medicine. and the natural sciences . Increased awareness of how the everyday relations between the sexes are formed is sought at all levels of education from preschool to university. It is believed that thorough changes. although they may take some time. are to be preferred to rapid changes. which might be spectacular but would be more superficial. 91 People working with the project are paid for their services . Since the collaborators are of value to the project mainly because of their professional contacts with various parts of the educational system. no one is employed full time . Everyone contributes by. for instance. revising curricula within his or her field of competence. The origin of the project is to be sought in the mid- I 970s. when the family planning council in Montenegro took an increasing interest in how the relations between the sexes are formed. Seven scientists were appointed to study the question and a project was drafted and presented to UNFPA . The project is funded jointly by UNFPA and the Republic of Montenegro. and the seven scientists who drafted the project still constitute its scientific core . About 20 other people are now working with them. To recruit them the original group approached institutes and schools and asked for suitable candidates. Since Montenegro is a very small republic with only half a million inhabitants. most professional people know each other and the original group obviously knew which candidates the various institutions and schools would suggest. There are four subprojects. On deals with preschool children. another with the compulsory school system. a third with higher education. and a fourth with intellectually handicapped children . In Yugoslavia the minimum school requirements arc decided upon by the central Government. Each republic is then able to issue detailed instructions and establish the curricula. The project aims at revision of all the curricula in Montenegro. including such subjects as art and physical training. A detailed analysis of the existing curricula has been completed. Improvements have been suggested for curricula or textbooks containing material relevant to sexuality and the relations between the sexes. Experimental curricula have also developed . m which special emphasis has been placed on the humanization of relations between the sexes. These experimental curricula have been implemented in a number of schools chosen by stratification on the basis of geography. nationality. and socioeconomic status. The experiment covers IO O ., of preschool children. 15 ° 0 of those in compulsory education. and 10 ° 0 of those in higher education . The experimental programme also covers something between 10 ';0 and 15° 0 of intellectually handicapped children. Knowledge and attitudes were pre-tested in teachers. pupils and parents of pupils. After one year of teaching according to the experimental curricula. the teachers and pupils will be tested again. So far the project has not encountered any opposition. Parents of the pupils in the experimental schools did not object to participating in the project when asked to fill in pre-test questionnaires . The task that has so far raised most problems is coordination of all the different sub-projects. It has also been found that the scientists who work with the project have sometimes a rather limited knowledge of life in schools. Character and financing of the project. The project is based on a thorough analysis of all existing curricula. the testing of experimental curricula. and the development of revised curricula . The project was 92 limited in time: it started on I January 1980 and continued until the end of December 1982 . For the entire project the UNFPA input is estimated at US $99 000 and the contribution of the Government at Din 14 million. In 1980 the UNFPA input was US $16000 and the Government input somewhat more than US $7000 . Personnel. Everyone working with the project is paid. but is employed elsewhere and used within the project only in his or her capacity as an expert. based on his or her regular employment. The project director is a professor of education at the Teachers College. Niksic . He is assisted by 24 other persons- teachers. sociologists. gynaecologists. psychologists. biologists. artists. etc. Since the number of possible candidates was very small. the procedure for the recruitment of stafT actually boiled down to self- selection. Target groups and characteristics ol clients. The project covers all educational stages from preschool to university. Pupils and students afTected by the project range from 3 to 24 years old . About IO 0 0 of the entire preschool school university population also participate in the experimental project with special curricula. It is believed that very few of those who are afTected by the project have had any previous sex education. Ohstac/es. The list of possible obstacles used when discussing the problems of service-providing programmes and projects is not relevant for a project of this kind and is therefore omitted. The main problem encountered thus far has. hardly surprisingly. been in the sphere of coordination. The financing has also sometimes caused more problems than was originally anticipated . Possihle themes and targets . Five themes were regarded as not important or not very important. all the others as important or very important. The five regarded as not important or not very im- portant are: the religious view of marriage and the family: pornography: masturbation: homosexuality: and sterilization. When asked about possible target groups for sex education. the view of those in charge of the programme was that preschool children. chi ldren at primary school . children at secondary school, adolescent girls. adolescent boys, girls just below the usual age of marriage. and boys just below the usual age of marriage were all very important target groups, the other groups not important at all. When asked about possible target groups for family planning activities . their view was that girls just below the usual age of marriage and boys just below the usual age of marriage were the only groups that were very important. Republic of S lovenia Slovenia is economically the most developed republic in Yugoslavia. Its cultural background is also markedly difTerent from that of the southern 93 republics; unlike the southern republics, it was part of the Austro- Hungarian Empire. Patriarchal traditions are less evident. In Slovenia 48 °0 of all women. more than in the other republics. are gainfully employed. Although less patriarchal than in the southern republics, traditions in Slovenia still impose heavy burdens on women employed outside the home since they still have the main responsibility for tasks in the home. Unlike Vojvodina but like Montenegro, Slovenia is ethnically homogeneous, but there are some immigrants from the southern republics who sometimes have to face cultural clashes that can be just as painful as those faced by immigrants in other countries. The real victims of these cultural clashes are young people, and young girls in particular. At the gynaecological clinic in Ljubljana it was noted that it seemed to be easier for girls from the southern republics to adopt the more liberal sexual habits of Slovenia than to adopt the contraceptive habits. Reproducrire unit , gynaecological clinic (former Family Planning Institute ) . Unirersiry Hospira/ , Ljubljana Since 1975 there have been special opening hours and special programmes for young people at the clinic. Every Monday between 07.00 and 12.00 about 30 adolescents participate in a special programme. They are first received for a lecture on the humanization of relations between the sexes. They are then given group motivation for family planning and an immediate possibility to have an individual consultation. The clinic also takes part in the premarital counselling which, according to a Slovenian law of 1977. is compulsory for all couples before they marry. Premarital counselling consists of four hours of lectures from various experts on law. medicine . psychology and social affairs. During these lectures family planning is touched upon and an effort is made to motivate the couples to adopt family planning. As regards the special adolescent programme, two features must be stressed. First it is co-educational. both girls and boys (although considerably more girls) participating. Individual counselling is offered to boys as well as to girls. but asked for considerably more often by girls. Second. through thi s programme young people are able to get contraceptive services much quicker tha n if they relied on the regular service of the reproductive unit. The demand for family planning services is so great that a patient may have to wait several months for an appointment: through the special adolescent programme young people are able to receive services after a considerably shorter waiting period . The contraceptive chiefly recommended to young girls is the diaphragm. Unfortunately supplies in Yugoslavia at present are small and the quality unreliable. Since Ljubljana is located close to the Italian as we ll as to the Austrian border the girls are often encouraged to go to Italy or Austria to buy diaphragms of the sizes prescribed at the clinic. When contraception fails there is always the possibility of a legal abortion in Yugoslavia . In 1980. 7132 abortions were performed at the gynaecological clinic: 351 (5 °.,) were on girls aged 18 or younger. 94 Unfortunately. young girls are over- represented in the group having late abortions: 9.5 °., of the rather few who had an abo rtion after the tenth week were aged 18 or less. Over-representation in that group is due to irregular menses and 1or psychological resistance to admitting pregnancy . Early abortions are performed by aspiration . Young girls wishing to obtain an abortion often show up without having made an appointment. The girl is then seen by a soc ial worker. pregnancy test s are carried out. and the gestation age computed. The financial and social situation of the girl is discussed with the social worker, and relations with her parents and the putative father are also discussed. If the girl decides to have the baby the parents are informed: if, on the other hand, she wishes to have an abortion the parents arc never informed by the clinic. Most of the young abortion patients are 17 or 18 years old. i.e. at an age when girls in Slovenia usually start intercourse . The youngest abortion patient at the clinic was 13 years old . Young girls very seldom have repeated abortions. For the very early abortions anaesthesia is not used, since it is considered to be an extra risk factor . but to make it eas ier for the girls in these cases social workers are usually present during the operation. The social workers regret that they do not have mo re time available for young people . As has been mentioned there are about 7000 abortions every year, about 350 on young girls: the three social workers at the clinic have to look after the needs of all of the clients and not only of the young. At the clinic it is believed that about 50 °., of adolescents who use contraceptives favour the diaphragm. IO 0 0 the condom. the remaining 40 °., the Pill. IUDs are not considered particularly suitable for young girls. In the period 1976- 1978 only 55 young girls received IUDs. Character and financiny of proyramnw Neither family planning nor the sex education of young people is the primary purpose of the clinic. but both are given to young people. The clinic participates in the premarital counselling which. according to Slovenian law. is compulsory before marriage. These activities are not separa tely funded. The cost for individual activities is thus not known . Everyone participating is a regular employee of the gynaecological department at the University Hospital. Personnel. The team regularly working with these special activities for adolescents consists of a female gynaecologist. a female nurse. and a female social worker. When necessa ry they can obtain the assistance of a male psychologist and also of other experts working of the depart- ment. Taryet yroups and characteristics of client. Participants in the special adolescent programmes are from 14 to 19 years of age and consist of both boys and girls. They are usually recruited through schools . Contacts are made with schools in the whole of Slovenia, not only in Ljubljana , the schools being encouraged to send whole classes to the clinic. The majority of the participants are. however. girls. Girl s can go to the clinic outside the hours set aside especially for young people . It is estimated that about half of the clients at the clinic are teenagers . It is 95 also estimated that the clinic serves about 10 ° 0 of the girls in the Ljubljana area. The special adolescent programme started in 1975. premarital counselling in I 977. The clients could go elsewhere to obtain contraceptive services. for instance to local health centres. The special recruitment procedure at the clinic. however. makes it easier of access to those who have not previously been to any family planning clinic. It is also believed that the comprehensive approach. which includes education and motivation and the services of socia l workers and psychologists . appeals to young people. Puhlici::ing the programme. The most important factor in making the special adolescent programme known is the regular contributions of the physician responsible for the adolescent project to popular magazines for young people. She writes regularly about sex and sexually related issues in a weekly magazine primarily intended for young people. She also regularly informs readers of the magazine about the activities of the reproductive unit. Ohstacles. As can be seen from Table 17. none of the obstacles listed was rated as an important problem. One additional obstacle was added: the lack of diaphragms. felt to be of importance since the diaphragm is the device most often recommended by the clinic. Possihle themes and rargets . Only four possible themes for sex education were rated as important or very important : sex roles: parenthood : contraceptives: and abortion. Items added were relations between the sexes: sex identity: and the role of parents and partners. The following targets for sex ed ucation were rated as very important : preschool children: children at primary school: children at secondary school: adolescent girls: and adolescent boys. Other groups were ra ted as of some importance or as not important at all. Girl s just below the usual age of marriage and boys just below the usual age of marriage were thought of as being only of some importance as target groups for sex education . although they were included in the target. The emphasis of the clinic was on children at secondary school and adolescents. Of the possible targets for family planning the following were rated as very important : girls just below the usual age of marriage: boys just below the usual age of marriage : young girls as soon as possible after the menarche: and young boys as soon as possible after the first emission of semen. These groups were also included in the target. All the re- maining groups were considered to be only of some importance as targets . Numher of clients .. 1·errices giren. and/ees . In 1980. 150 boys and 800 girls received sex ed uca ti on through the speci al adolescent project : 700 girls received contraceptive serv ices: and 100 girls received counselling se rvices. Among the girls about 50 °0 were prescribed oral contraceptives. the remaining 50 ° 0 measured for diaphragms and recommended to use th em. If diaphragm s had been more easi ly available a larger number of the girls would have been recommended to use them . Of all the clients. 96 Table 17. Reproductive unit, gynaecological clinic , Ljubljana: rating of possible obstacles Possible obstacle Potential clients have too vague an idea about family planning Potential clients are hostile to family planning Potential clients are hostile to sex educat ion Parents of potential clients object to fam ily planning for young people Parents of potential clients object to sex education for young people General traditional values in society I I literacy The uncooperative attitude of boy friends That it is not socially recognized that young people have intercourse The geographical location of the programme/project centre makes it difficult to reach Business hours of the programme/project make it difficult for potential clients to get in touch Other organizations/institutions do not tell potentia l clients about project Constant risk of being forced to close due to lack of money Constant risk of being closed down due to lack of political support Lack of specialist personnel Lack of voluntary workers Lack of continued training of personnel Problems of cooperation among staff Lack of clearly understood objective Lack of clearly defined target group Lack of equipment • 1 = No problem whatsoever 3 = Some problem 5 = Severe problem. Indicat ion of importance 8 3 1 1 3 3 3 3 3 3 3 1 3 1 1 1 3 3 3 including adult s. a t the clinic. abo ut 30 ° 0 were recomm ended spermicides a nd /o r diaphragms. 40 °11 rece ived IUDs. and 30 °0 rece ived o ral contraceptives. The spec ial ado lescent project is operati ve from 07.00 to 12. 00 once a week. Premarit a l co un selling receives 6- 8 hours a week. Adolescents either a ttend th ro ugh the ado lescent programme. to which ado lescents a re rec ruited in groups. o r ma ke indi vidua l contact with the clinic. Young people teleph oning fo r a n a ppointment se ldom have to wait mo re tha n a month . a t thi s clinic a ve ry sho rt waiting 97 period since adults have to wait for more than six months and sometimes up to a year. Clients do not pay for the services offered at the clinic . Summary of ratings made in the projects and programmes studied The numbers of projects and programmes making a specific rating appear in Tables 18- 21. Table 18. Rating of obstacles by number of projects/programmes No. of projects/programmes by indication of importance• Possible obstacles Potential clients have too vague an idea about family planning 1 Potential clients are hostile to family planning 8 Potential clients are hostile to sex education 9 Parents of potential clients object to family planning for young people Parents of potential clients object to sex education for young people 3 General traditional values in society 1 Illiteracy 6 The uncooperative attitude of boy friends 4 That it is not socially recognized that young people have intercourse 3 The geographical location of the programme/ project centre makes it difficult to reach 7 Business hours of the programme/project make it difficult for potential clients to get in touch 8 Other organizations/institutions do not tell potential clients about project 7 Constant risk of be ing forced to close due to lack of money 5 Constant risk of being closed down due to lack of political support 8 Lack of specialist personnel 7 Lack of voluntary workers 9 Lack of continued training of personnel 4 Problems of cooperation among staff 8 Lack of clearly understood objective 5 Lack of clearly defined target group 5 Lack of equipment 3 98 • 1 = No problem whatsoever 2 = Some problem 3 = Severe problem. 2 1 4 1 2 3 4 3 1 4 3 3 2 2 1 1 1 5 2 4 4 3 8 2 4 6 4 2 6 2 2 3 2 3 1 6 4 4 4 4 3 2 5 2 2 2 2 2 2 3 2 1 1 5 2 3 2 Table 19. Numbers of programmes/projects answering the question: " Which of the following themes are considered to be important in the sex education of young people according to the point of view of the programme/project? " We would also like you to indicate whether any of these themes are compulsory in sex education or, on the other hand, considered totally unsuitable for young people according to official (government) policy." No . of programmes/projects No. of programmes/ indicating respective projects perceiving importance• government policy as: 2 3 4 5 compulsory not fit for young people Sexual anatomy of humans 5 9 8 Sex roles 1 13 4 Parenthood 2 2 9 7 Reproductive biology 4 2 8 8 Love 1 2 12 2 Psychology of puberty 2 2 1 10 3 Religious view of marriage and the family 7 1 4 1 2 4 2 Pornography 2 3 5 2 2 1 4 Intercourse 1 2 6 6 1 1 Petting 2 3 8 1 1 Masturbation 1 2 3 8 1 1 Homosexuality 2 3 6 4 1 1 Contraceptives 3 12 3 1 Venereal diseases 2 4 8 4 1 Sterilization 6 7 1 1 1 1 Abortion 3 2 10 2 1 Sexual dysfunctions (e.g . impotence) 2 3 5 5 • 1 = Not important at all 3 = Of some importance 5 = Very important. T able 18 is a summary of the tables presented individually for the projects and programmes studied. The obstacles most frequently mentioned as constituting problems are that parents of potential clients object to family planning for young people. that it is not socially recognized that young people have intercourse. and that there is a constant risk of being forced to close due to lack of money . The first two reflect the cultural values of the social surroundings of the programmes and projects and can be expected to change only gradually. The third obstacle. lack of funds . is usually the result of systematic lack of support from governments and could be readily remedied. The adverse effects of too early pregnancies are too evident to be ignored and every society ought to avoid their occurrence . 99 Table 20. Numbers of programmes/projects answering the question: " Which of the following groups is it important to reach with sex education according to the point of view of the project , and which groups (if any) are included in the present target for the activities of the programme/project?" No. of programmes/projects No. of programmes/ indicating respective projects including importances the group in present activities Target group 2 3 4 5 Preschool children 2 3 1 6 1 Children in primary school 2 1 2 8 3 Children in secondary school 1 3 12 7 Adolescent girls 15 12 Adolescent boys 14 11 Girls just below usual age of marriage 11 8 Boys just below usual age of marriage 1 10 7 Newly married women 3 8 3 Women with many children 5 7 3 M en with many children 6 6 3 • 1 = Not import;;nt at all 3 = Of some importance 5 = Very important. A very simple and , compared with the cost of the rest of the health es tabli shment, cheap way of avoiding them is to promote special services for yo ung people who, for the various reasons discussed in this volume, are often reluctant to take advantage of regular family planning services even when they are formally available to them . Table 19 summarizes the ratings for various possible themes for sex educa tion in the projects and programmes and can be compared with Table 3, which contains a summary of the answers of governments. Table 20, which summarizes the ratings of various target groups for sex educa tion, can be compared with Table I, conta ining the same summary for governments. Finally. Table 21, which summarizes the ratings of possible target groups for family planning. can be compared with Table 5, which summarizes the answers of governmen ts. Since the programmes and projects do not form a representative sample, comparisons have to be made cautiously . Some differences. however, need comment. The answers from governmen ts indicated three topics as particularly important : the biological foundations of sexua lity (sex ua l anatomy. reproductive biology); parenthood; and contraceptives. The themes most often considered important or very important by the programmes and projects are somewhat different. The theme most often rated as important or very important is, hardly surprisi ngly since we a re dealing mainly with service-providing projects, contraceptives. In 100 Table 21 . Number of programmes/projects answering the question: " Which of the following groups is important to reach with family planning /counselling services according to the point of view of the programme/project, and which groups (if any) are included in the present target group for the activities of the programme/proiect7 No. of programmes/projects No. of programmes/ indicating respective projects including importance• the group in present activities Target group 2 3 4 5 Women with many children 3 1 2 7 3 M en w ith many children 4 1 1 7 2 M arried women 3 1 3 6 3 Married men 4 1 2 6 2 All adult women 3 2 3 5 2 All adult men 4 1 3 5 2 Newly married women 3 2 2 6 3 Newly married men 4 1 1 7 3 G iris just below usual age of marriage 2 9 7 Boys just below usual age of marriage 2 9 7 Young girls as soon as poss- ible after menarche 2 2 8 9 Young boys as soon as poss - ible after first emission of semen 1 2 8 9 • 1 = Not important at all 3 = Of some importance 5 = Very important descending order of importance. the important themes according to the programmes and projects were love, sex roles, intercourse and abortion. The projects and programmes seem to favour sex education that is more centred on the individual and his or her relations to other individuals (love. sex roles. intercourse). The governments. on the other hand. seem to prefer sex education that places less emphasis on the individual and more on the biological foundations of sex uality and its socia l consequences (sexual ana tomy. reproductive biology. and parenthood). The projects and programmes agree with the governments on the primary importance as targets for sex education of adolescent boys and girls and chi ldren at secondary school. In relation to the ra tings of possible target groups for family planning. the projects and programmes tend to discriminate between the possible target groups to a lesser extent than the governmen ts. On the whole. a ll the groups are considered important or very important as 101 target groups. Table 21 shows that young people a re included in the ta rget group twice as often as the other groups. this being a result of the projects and programmes having been se lected to provide services to young people. That only nine projects and programmes state that young people are included in the target is because some programmes that have no particul ar target but welcome anyone who comes to them have not specified which groups they offer se rvices to. since they have not rated their actual clientele as a target. 102 Conclusions Education 4 Conclusions and recommendations In none of the countries that answered the questionnaire is sex education forbidden by law. In several the legal situation is unclear since the matter is not regulated by explicit laws or regulated at all. but education on sex ual matters does not seem to be illegal in itself. Starting sex education depends . however. on local initiative. Such local interest is an important aspect of sex education in many, if not all, of the countries where it is compulsory in schools. The actual, as distinguished from the formal. implementation of sex education always depends on the interest and cooperativeness of local authorities such as school boards or head- masters. Without their cooperation even the most impressive curriculum would be no more than a dead letter. An interesting difference was found between the views of govern- ments and the views of the projects and programmes studied. The sex education preferred by governments is characterized by emphasis on the biological foundations of sexuality. parenthood, and contraception, a combination that may be regarded as a predominantly demographic - rechnical approach. The approach preferred by the projects and programmes studied cou ld be described as indil"idual- re/arional. since the emphasis is on contraceptives. love. sex roles. intercourse. and abortion. an emphasis th a t was confirmed at the discussions held during the study vis it s. Almost all project s and programmes found that the sex education their clients had received prior to initial contact with them was non- existent or inadequate, even in countries where sex education is compul sory. That some kind of education on sexual matters is compulsory in schools does not guarantee that it will be adequate or that the pupils will be receptive . It is often taken for granted that if sex education is given the pupils will soa k in the information like sponges. The experience of countries where sex education exists on a fairly wide sca le does not validate such an assumption. 103 Services The project s and p rog rammes studied have ve ry difTe re nt a pproaches a nd o perate unde r ve ry difTerent conditio ns. Some arc fin a nced by va ri o us mini stries a nd a re a bl e to pl a n the ir acti viti es o n the reasona ble ass umptio n th a t funding will continue. Others wo rk unde r the threat o f in suffici e nt funding a nd lac k of suppo rt. The difTerent a pproac hes fa ll into three broad ca tego ri es. So me o f the projec ts a nd p rogra mmes fit eas il y into the ca tego ri es . o the rs fa ll between them: but ca tego ri za tio n ma kes it eas ie r to dete rmine the ac tio n needed to s trengthe n the projec ts and progra mmes . Th e fir s t ca tego ry is the enthusia sts. who love their wo rk and arc willing to put up wi th co nsid era ble hard ships to furth e r the ca use th ey advoca te. For them there is littl e di fTe rence betwee n their wo rk with the projects o r p rogra mmes a nd the res t o f the ir life. U n fo rtun a tely. they a re a lso o ften ama teurs in the sense th a t they a rc insuffic ientl y t ra ined to provide services. Thi s mu st no t be unders tood as mea ning th a t th ey lack professio na l competence in their fi eld : th ey are o ften exce ll ent and we ll trained phys ic ia ns. soc ia l wo rk ers. e tc. They do. ho wever. lack sufficient t ra ining in the prov ision o f se rvices and . mos t impo rt a nt o f a ll. they lac k instituti ona l contac ts a nd suppo rt from gove rnment ins tituti ons and have d iffic ult y in dea ling wi th o ffi c ia ls a nd inst ituti o ns so as to furthe r the ir p rojec ts. A imer Jeuncs in Brussels a nd the AP F in Lis bo n may be mentio ned as exa mpl es . Th e seco nd ca tego ry is the pro fess io na ls wh o a rc charac te ri zed by the ir awa re ness o f their profess io na l experti se a nd a we ll deve lo ped wish to share it with o th ers. lettin g th e c lient s profit from it. U nlike the enthusiast s. they a rc no c ru sade rs: they a rc s impl y d o ing their pro fess io na l dut y. Thei r rela tion to the ir client s is quit e difTe rent fro m th a t o f the enthu sias ts. o ne th a t ma kes it quit e clea r wh o is the provide r a nd who is th e receiver . P rojec ts a nd progra mmes wo rking under difficult econo mic conditi o ns. as well as those cha racte ri zed by sta ble a nd suffici ent fundin g. bo th fa ll into thi s ca tegory. Amo ng those studied Pl anning Josa ph a t in Brusse ls may be menti o ned as a good exampl e of the g roup wo rking under diffi c ult econo mic co ndi tions. the Rutge rshui s in th e Hag ue as a n exa mpl e o f th ose wo rking unde r favo urabl e conditio ns a lth o ugh the la tt er has some fea tures o f th e third ca tego ry. The th ird ca tego ry 1s the institutio na lized . U nlik e the o the r catego ri es. th e term does no t refe r pr ima ril y to th e persons wo rking within it but to the p rojec t o r p rogra mme it sel f. reasona bl y eno ugh since th e p rojec t o r prog ramme depend s much less o n the indi vidua l ch a racte r o f th ose work ing with it. The p rojec t o r programme has beco me a n in s tituti on and vaca ncies co uld in principle be fill ed b y a ny fo rma ll y compe tent a ppli ca nt . Prog rammes a nd p rojec ts bel onging to e ither o f the fi rst two ca tego ri es depe nd to a much g rea te r ex tent o n indi vidual pe rsona liti es. ins ti t ut iona li zed p rogra mmes and projec ts o n competent sta fT. Be in g in sti tut iona li zed . th e projec ts a nd p rogra mmes a re att ac hed to a bureaucracy fro m wh ich funds a rc o bta ined and with which rul es 104 are negotia ted for the ac ti vities pursued . The best example o f a project or programme of thi s kind is the Ado lescent Clinic of the Stockholm School Board. Another example is the federation clinic in Wa rsaw. This division into categories does not imply that any o ne category is best. Owing to the different condition s the projects and programmes of all three types are important. The institutionalized type, fo r instance, would be to tall y ineffectual if the o rganization or bureaucracy to which it belonged adopted a n unfavourable att itude towards fa mily planning for yo ung people. In stitu ti ona lized projects and programmes, too, always run the ri sk of individual staff members becoming institutionalized themselves, civil servants rather than se rvice providers. The professiona ls run the risk of becoming iso lated in their professional roles, los ing the ability to adapt themselves to the cha nging needs of their clients . They also run the risk of becoming to ta ll y self- sufficient, incapable of cooperating to promote serv ices to other than their own clients . The enthusiasts are probably necessary to provide a ny services at a ll under un favourable circumstances and to increase public awa reness of the need for them . They run the great ri sk of ending in frustration because of the many difficulties they encounter, which are at least part ly the result of their limited abi lity to manage things to the adva nt age of themselves and of thei r programme or project. Some of the projects and programmes cannot be used as examples of a single catego ry but lie between two catego ries si nce they have features of bo th . Pro Familia , Frankfurt, for instance seems to thrive on a coali tion of en thusiasts and professionals: and the fami ly planning counci l in Novi Sad seems to be a mixture of professionals and the institutionalized . Recommendations Education I . Legislation should be enacted in all countries for compul sory ed ucati on on sexua l matters . 2. School curricula should be developed in all countries not onl y for sex educa ti o n in the narrow sense but also for sexua lity, sexua ll y related matters, and relations between the sexes, taught wherever appropriate by various profess ions . 3. All countries , in developing curricula, should ensure th at the ed uca ti on given is not only comprehensive and understa ndab le by the pupil s but is a lso felt by the pupils to be relevant to them . In that connexion considera ti o n sho uld be given to the finding tha t the projects a nd programmes studied tend to advoca te a n individual - relational sex educa tion , centring not only o n contraceptio n but a lso on love, sex roles , and the sexual ac t as opposed to the mo re demographic- technical approach that seems to be prefe rred by gove rnments. 105 4. All countries should suppo rt loca l initiati ve a nd undert a ke programmes to mo ti va te loca l officia ls. headmasters and teachers. as a pre requi site to the success ful implementa ti on o f any educa ti o n on sex ua l ma tt e rs. Services Measures sho uld be ta ken to ensure the avai lability of spec ia l c linics to yo ung peo ple in a ll co untri es as a pa rt of the regul a r hea lth system. Such clinics are pa rticula rl y urgent since ado lescent sex ua l enco unters have become mo re comm on in recent decades. irrespecti ve of whether they are socia lly accept ed o r no t. and adequa te se rvices a re needed to avo id the harmful effec ts o f too early childbea ring: forced marria ges. aborti on (legal o r illega l). ruin ed educati ona l pl ans. a nd socia ll y and economica ll y imm a ture pa rent s. To prevent too ea rl y and unwanted pregnancies as well a s sexua ll y tra nsmi ssible di seases. adequate educa ti ona l se rvices a re necessa ry. Since regul a r fa mil y planning se rvices have everywhere p roved insufficient ( judging fr o m the increasing pregnancy rat es a mong yo ung people) specia l se rvices a re needed tha t a re no t onl y ava ilable but a lso acceptable to yo ung people. Yo ung people must have confidence in the se rvice providers a nd be certa in tha t they will not be pa tronized . encounte r mora liz ing a ttitudes, o r have to fea r that their sex ua l acti vities will be di sclosed to pa rent s o r other people in their soc ia l surroundings. If confidence in the se rvice-providin g o rganiza tion is absent. as it is in most cases. ado lescent s will absta in from using the se rvices fo rm a ll y o ffered to them. Since the enthusiasts o ften wo rk under conditions where they ca nn ot count on suppo rt fro m the local administration, and since se rvices within the ir own co untry a re no t very well deve loped . they sho uld be given sufficient suppo rt . not o nl y increased fund s but a lso continued training and the poss ibility to lea rn from the ex peri ence of others. pa rticul a rl y in o ther countries. The p ro fess io nals sho uld be granted o ffi cia l recogniti on of their projects and p rogrammes so tha t they can be adequately fund ed. They sho uld a lso be enabled to ma ke increased contac t with o ther service providers with who m they can compa re experiences . Since the institution a li zed have vas t kn owled ge o f the technica l o rganiza tio n of services, they should sha re it with o thers. They should intensify contacts with other p rojec ts a nd programmes, and pa rticul a rl y with those which a re not institutiona li zed. Projects and programmes should not be bureaucratized . T o achieve these obj ecti ves the fo ll ow ing meas ures a re p ro posed . I. In a ll countri es spr .i a l famil y pl anning clinics for yo ung peo pl e sho uld be es ta bli shed providing necessa ry cont racepti ve as well as coun selling se rvices. 2. Progra mmes sho uld be deve loped at the region al a nd nati ona l level for the continued training of se rvice providers, in which the less experienced can learn from the more experienced and the more 106 experienced. through contacts with developing projects and services. learn about recent developments in approaches to and the organization of services. 3. A network of contacts between the service providers should be developed at national level to facilitate the exchange of information . which is now almost totally lacking. 4. International contacts between the service providers should be developed at the regional level through courses. seminars. and working groups. Such contacts are important for all service providers. but particularly for those who work in countries where the development of services is still at the initial stage. 5. Contacts between intern a ti onal organizations and projects and programmes working under unfavourable circumstances should be strengthened . since the lack of local support makes the monitoring and development of projects and programmes extremely difficult. 6. Systems of financing should be developed at the national level under which governments take increasing responsibilit y for the se rvices provided to their young citizens and permit projects and programmes to plan for longer periods of time. The present uncertain state of funding in many cases leads to misuse and waste of professional resources. 7. New projects and programmes offering special services to particularly vulnerable groups such as immigrant adolescents should be developed at regional and national level and existing ones strengthened. 107 References I. The child and the adolescent in society: report on a WHO Conference. Copenhagen, WHO Regional Office for Europe. 1979 (EURO Reports and Studies No. 3). 2. Kozakiewicz, M. Sex education and adolescence in Europe: sexuality , marriage and the family. London. Interna tiona l Planned Parenthood Federa tion, I 98 I. 3. WHO Technical Report Series No. 476, 1971 (Family planning in health serrices). 4. Swartz, B. Family planning legislation: report on a survey . Copenhagen. WHO Regional office for Europe, 1983 (EURO Reports and Studies No. 85) . 5. Approaches to selected groups: report of a regional travelling working group that visited the Federal Republic of Germany. France, the Netherlands, Poland and Sweden, September I 977- February I 978. London. Internation al Planned Parenthood Federation, 1979. 6. Dengler, U. et al. Projek trorstudie piidagogische und beraterische lnten ·ention im Bereich Sexualitiit und Familieplanung bei Soldatcn der Bundes~rehr . Frankfurt am Main, Pro Familia, 1980 (Pro Familia Projektberichte No . 5). 7. Research needs and approaches in adolescent reproductfre health in dere loping countries of the WHO European Region: report on a working group. Copenhagen, WHO Regional Office for Europe, 1981 (document lCP/MCH 023) . 109 Annex 1 SELECT BIBLIOGRAPHY This is a bibliography of recent material for those working with family planning and the sex education of young people in the WHO European Region. "Recent" here means that books, articles, etc. published during the I 960s are included only sparingly and older material is not included at all. The bibliography does not aim to be complete, but to aid the planner as well as the field worker trying to implement services and wishing to learn from the experience of others. That the bibliography is primarily concerned with material relevant to the WHO European Region is attributable. among other things. to the fact that it forms part of a study by the WHO Regional Office for Europe. The Region includes Scandinavia as well as North Africa and the cultural patterns within the Region are in many respects dissimilar. The main objective has therefore been to make the bibliography relevant and easy to use for those working in the Region. Non-European material is generally excluded. while articles with no special reference to country or region are included even though Europe is not particularly referred to. The stress is on sen-ices. the bibliography being meant more for the provider and planner of services than for the scholar. It is designed to enable the planner and provider to find refe rences to works portraying the efforts and results of others within their respective societies. Articles that focus on purely medical aspects (i.e. more on the strictly medical contents of a service than on its form, condition. availability, and structure) have generally been excluded. Examples are the numerous articles dealing with the relative advantages or disadvantages of IUDs as compared with other contraceptives for young girls, and unless they contain references to service research, general reviews of adolescence and reproductive health. General sociological and statistical studies on adolescent sexual behaviour have also been excluded unless they refer to services or can m some other way be classified as service-oriented research. Most articles m thi s field of study have been published in the local language. Since a bibliography (and particularly an annotated one) containing works in all the languages used within the Region would be of little practical use. material in languages other than English. French and German has been excluded unless it contains summaries in one of those languages . The bibliography is divided int o three major sections: ~ material dealing primarily with. or directly relevant to. family planning and the sex educati on of young people in the European Region. 110 - material dealing with family planning or sex education but not primarily concerned with young people or Europe . - other at least partially relevant material. e.g. bibliographies and project catalogues . Under each section the material has been divided into two categories under the subheadings "United Nations and specialized agencies" and "other material". the reason being that material from the United Nations and the specialized agencies often contains reviews that arc more general than other articles . Needless to say. in a number of instances the classification of an item in one section rather than another can be disputed. It is. however. believed that the division of the material into three broad categories will help the reader to find material suited to his or her particular needs. The reader is asked to help improve the bibliography by providing any references that he or she feels ought to be included in forthcoming editions. FAMILY PLANNING AND SEX EDUCATION OF YOUNG PEOPLE IN THE WHO EUROPEAN REGION United Nations and specialized agencies Consulta1ion on co111racep1ion in adolescence . Geneva. 8 IO September 1975 . Geneva. World Health Organization. 1976 (unpublished docu- ment MCH /761). 22pp. This report forms part of a 1976 WHO review on the reproductive health needs of adolescents prepared for an expert committee to examine the safety. effectiveness. and acceptability for adolescents of currently available contraceptive methods during the critical physiological and psychological maturation process of adolescence. The chapter headings are: Definition and magnitude of a problem: Physiology of adolescents: Medical characteristics of contraception: Non-medical factors: Sex education and reproductive health; Conclusions and recommendations. WHO Technical Report Series. No. 483. 1971 (Heall/, education in heal!!, aspec1.1· o/'family planning: report of a WHO Study Group). pp. 47. This report of a study group that met in 1970 notes that in many countries the integration of family planning into the health services not only has important educational implications but also brings many administrative and technical advantages. It also notes that. regardless of the primary objective of family planning. its final success depends on people- the decisions they make and the actions they take. Some important requirements and difficulties as perceived by the group are listed and commented upon . The report concludes with nine recommend- ations to the health authorities in relation to the health aspects of family planning. 111 WHO Technical Report Series, No. 583, 1975 ( Pregnancy and ahortion in adolescence: report of a WHO meeting). pp. 28. This 1974 meeting was convened to: (a) review the current situation in relation to pregnancy and abortion in adolescence in different cultural settings; (h) identify variables that influenc!': sexual and reproductive activity in adolescence; (c) identify special characteristics of reproductive health in adolescence; and (d) review current and projected research and service needs . The report contains not only comments on adolescence and pregnancy but also specific recommendations on the services that might be offered to adolescents. Puech, F. Teaching of' family planning at medirnl. nursiny and mid1riji,ry schools in certain countries of' the ffyion: report on a study Copenhagen , WHO Regional Office for Europe. 1979 (unpublished document ICP/ MCH 015. FNUAP/ RER 72 /PO9), pp. 47 . This study reviewed the teaching of family planning at medical. nursing and midwifery schools in selected countries. developed a model for organizing the teaching of family planning. and recommended improve- ments. The selected countries were France. Italy. the Netherlands , Poland, Sweden. the United Kingdom, and Yugoslavia. The report strongly recommends multidisciplinary training in family planning. this giving each category of staff a clearer understanding of its role within the responsible team and , by the same token , a better appreciation of the roles of other members of the team. Such an approach is believed to avoid lo~s of time. disorientation , disappointment. and rejection among young people in need or in difficulty . Reference is made to such an experiment under way for a number of years at a university in one of the countries studied. which according to the author ought to serve as a model. Unfortunately. no details are given except that the experiment was supported by WHO. But the report contains detailed descriptions of the organization of teaching in the countries studied. Report of a WHO meetiny on adolescent .1ex11ality and reproductire health: educational and serrice aspects , Mexico City. 28 April-2 May 1980 (unpublished document). pp . 76. To fill the gaps in information on the reproductive health needs of adolescents and the information. education. and services available to them. WHO collaborated with the International Planned Parenthood Federation in the design and implementation of a cross-cultural survey. The document reports on the results . It contains a conceptual model of various perspectives on services, a design for strategy . and specific recommendations for future work in this field. An annex contains the country and area surveys. Country profiles are available for Czechoslovakia. Ghana. Hong Kong. Indonesia. Italy, Mexico. New Zealand. Senegal. Thailand, Turkey. and the United Kingdom . Special area profiles are also available for India (Bombay). Italy (Trieste) . New Zealand (Willington). the United Kingdom (Exeter), and the United States (California . Colorado. Illinois, Pennsylvania). 112 Research needs and approachC's in adolescenl reproductit·e heal!h in ckrl'lopin(J countries of the WHO European Region: Report on a working group convened jointly by the WHO Regional Office for Europe and WHO Headquarters. Lisbon. 4- 8 August 1980. Copenhagen. WHO Regional Office for Europe. I 98 I (unpublished document ICP/MCH 023). pp . 23. Thi5 report points out that adolescence is a particularly vulnerable period in human life but that existing health programmes are little. if at all. concerned with adolescence. It also observes that sexual activity now begins ear lier in life in many cultures: hence early pregnancy. with its socia l consequences and medical risks for both mother and baby. is a problem that must be dealt with urgently. The report also contains country descriptions including the background. research priority issues. and research action plans for Morocco. Portugal. Turkey. and Yugoslavia. Recommendations for research and services are included. Sai, F. T. Adolescenl sexuali1y and rC'produclire heallh: some key issues for discussion. Unpublished background paper for a WHO Meeting on Adolescent Sexuality and Reproductive Health. Mexico City. 28 April - 2 May 1980. pp. 11 . The conclusion of this background paper is that adolescence is being largely considered by western societies as a problem period rather than as a distinctive and normal period in human development. This has led to problem-based approaches to programmes specially geared to ado lescence. The time has come to take a fresh look at the subject and to devise more comprehensive development-oriented approaches to the entire question of ado lescence. Serrice-orien!ed research in adolescent feniliry: report on a WHO meeting, Warnemiinde, 24- 27 April 1978. Copenhagen. WHO Regional Office for Europe. 1979 (EURO Reports and Studies No . I). pp. 37. Concern had previously been expressed by WHO about the relative lack of a ttention paid to adolescents. their medical and social needs. and the services available to meet those needs . The meeting was convened to discuss research into service-oriented aspects of adolescent fertility. the intention being to contribute to a better understanding of existing services and needs in relation to adolescent fertility . The report contains not only definitions of adolescence but also a review of the characteristics and problems of adolescence. It also recommends research and outlines a number of possible approaches. Finally. there is a discussion on the appl ication of research find ings to the development of ado lescent fertility programmes in the developing areas of the Region. Srudy on !he eralualion of family planning proyrammes: report on a planning meeting. Copenhagen. I 0- 12 December 1980. Copenhagen. WHO Regional Office for Euorpe. I 98 I (unpublished document ICP/MCH 025). pp. 11. II 3 This report on a planning meeting contains a short draft outline of proposed national programme eva luations. Material other than from the United Nations and specialized agencies Abschlussberich M odellprojek t "Craperine "_ Hannorer und Villingen Schwenningen. Frankfurt am Main . Pro Familia. Deutsche Gesellschaft fiir Sexualberatung und Familieplanung e.V.. 1979 (Pro Familia Projektberichte. No. 2), pp. 151 . This document contains three difTerent reports . The first is on the adaptat ion of the original English project "Grapevine" (which was speciall y designed to make family planning and sex education services available to adolescents) to the social reality of the Federal Republic of Germany. The second report discusses the experience of the local "Grapevine" project in Hannover. the third report the experience of the project in Villingen-Schwenningen . Advising the young: Peggy Follis interviews Dr Stalker. Norum, January 1979. p. I. This text is a short interview with a community physician on the experience of a special adolescent advisory clinic in Great Britain . Approaches to 1·elected groups: report of a regional travelling working group that visited the Federal Republic of Germany, France, the Netherlands. Poland, and Sweden, September 1977- February 1978 . London. International Planned Parenthood Federation , 1979. Taking as a point of departure the fact that the groups most in need of family planning services are often under-represented among clients, this document reports on five difTerent approaches towards reaching such groups. There are detailed reports from : "Youth campaigns" in the Netherlands: " Open House" clinic in Stockholm: "Quarter" in Grenoble: "Military" in Poland, and "Grapevine" in the Federal Republic of Germany . von Baross, J. Endbericht ::urn Projekt Mobile Beratungssrel/e . Frankfurt am Main, Pro Familia, Deutsche Gesellschaft fiir Sexualberatung und Familieplanung e.V ., 1979, pp. 32. This is the final report from a special project of the German Family Planning Association that was aimed at making sexual advice more easily available to young people by means of mobile information cen tres. Bergstrom-Walan, M.-B. Sexualerziehung in Schweden . In : Bergstrom- Walan , M .- 8 . et al. Model/fall Skandinavien? Sexualitiit und Sexual- politik in Diinernark and Schweden. Hamburg, Rowohlt , 1970, pp. 48 . This is a report on sex education in Sweden. A special section is devoted to the historical background, other sections to the sexual education of particular groups and in specia l settings. Finally, the question to what 114 extent sex education in Sweden can be regarded as a model for other countries is discussed . Dengler, U. et al. Projektrorstudie piidagoyische und heraterische lnt errention im Bereich Sexualitiit und Familieplanung hei Soldaten der Bunde.nrehr. Frankfurt am Main. Pro Familia. Deutsche Gese llschaft fur Sexualberatung und Familieplanung e.V .. 1980 (Pro Familia Projektberichte. No . 5). pp. 208. This contains four diffe rent reports that all deal with sex education and family planning for so ldiers in the army o f the Federal Republic of Germany. The first report dea ls with how young men are initiated into the role of so ldier. The second deal s with the army-sexuality relation ship and the so ldiers' images of male and female roles. The third discusses difficulties in communication under the heading of taboo discussion s. The last deals with advisory se rvices for so ldiers. Deschamps, J. P. Adolescent fertility in France. Paris. International Chi ldren's Centre. University of Nancy I. Nancy. 1978 (unpublished document) . pp. 16. This short paper gives data about the age of puberty. the menarche. the age of marriage. etc. as well as about the se rvice programmes available in France during the late 1970s. Deschamps, J. P. & Valantin, G. Pregnancy in adolescence: incidence a nd outcome in European countries. Journal o( hiosocial science. Suppl. 5 ( 1978). pp . 15 . This paper present s stati stical data o n the fertility rates. abortions. marriage rates. and sex ual beha viour of adolescents in Europe. Deschamps, J. P. Jugendlich e und Schwangerschaft. Der Kinderar::: t . 11. No . 11 ( I 980). pp. 3. This short article o n adolescent pregna nc y identifies the spec ial ri sk factors. Fricke, S., Klotz M. & Paulich P. Se.rnaler:::iehuny in der Praxis: ein Handhuch .fi"ir Piidayogen . Bera ter . £/tern und (l/1(/ere. Koln . Bund Verlag. 1980. pp. 358. According to the subtitl e. thi s is a ha ndbook for teache rs. se rvice personnel. parents. a nd o the rs. The book present s basic facts on sex uality and adolescent sex ual beha viour toge ther with comments based on extensive experience of advisory work in the Federal Republic of Germany . Grosch, R. Interk11lt11re//e Studie i.iher Aspekre der Fami/iep lmwng Ufl(/ Se.nwlpiidayogik hei Juyend/ichen - lnr ernarional Planned Parenrhood Federation ( IPP F) Europa Reyion . Beirray i.iher die BRD 1/1/(I Wes/- Berlin. Frankfurt a m M ai n. Pro Familia. Deut sche Gesellschaft fur Sexualberatung und Familieplanung. c.V .. 1978 (Pro Familia Arbeitsmaterialen. No . 13 ). pp. 67. 115 This report is the Federal Republic of Germany contribution to a cross- cultural study by the International Planned Parenthood Federation. It presents data from recent Federal Republic studies on sexual develop- ment. attitudes to sexuality. sexual beliefs, age at and conditions of first intercourse . contraception. family life expectations, homosexual ex- perience. and drugs. Gunn, A. D. G. contraception and students. Norum, January 1979. pp. 2. This short article maintain s that student health services have tradition- ally been ahead of subsequent social changes and that student health services today offer effective contraceptive advice . Hayman, S. A service for the young: Brook Advisory Centres. Nol'um, May 1981. p . 2. This is a short article on the experience of the Brook Advisory Centres. which offer clinical services and advice on contraception to the young and unmarried and. where appropriate . provide contraceptives. Hea/rh educarion i11 rhe pro/t'ssional preparario11 <Jf Seo/fish reaehers. I . Merhods adopred. Stirling. University of Stirling. Department of Education . Health Education Project. pp. 18. This is the first in a series of research reports on professional preparation for health education . The methods and the questionnaires used are presented . Healrh educario11 i11 rhe pro/t'ssional preparario11 of Seo/fish reaehers. 2. Srudenrs • reco/lecrio11 of healrh ropics ar school. Stirling. University of Stirling. Department of Education. Health Education Project. pp . 56 . This. the second report in a series on professional preparation for health education. discusses what pupils remember from the health education they received and various approaches to health education. Conception and contraception are among the twelve health education topics discussed . Herbst, U. & Kerscher, I. Srudie ::um Bedar/ a11 Aus-. Forr- u11d Weirerbildungseinrichrungen fiir Familienplanung . Se.rnalherarung und Sexual-piidagogi/.; in der ausserschulisehen Jugenarheir. Frankfurt am Main. Pro Familia. Deutsche Gesellschaft fiir Sexualberatung und Familieplanung e.V ., 1979, pp. 98. In this document there is a wide-ranging discussion of a number of educational opportunities open to those who work with out-of-school youth . The report also contains an impressive amount of statistical data on changes in adolescent sexuality in the Federal Republic of Germany . Hutchinson, F. Contraception and young people . Nornm. September 1979, pp. 2. In this short article the author discusses such issues as confidentiality. 116 choice of method. and other needs of adolescents resulting from early sexual acti\'ity. Illsley, R. & Taylor, R. Socioloyirn/ aspecr.,· of 1£'£'11a?J£' pre{JnanlT. Aberdeen. Uni,-crsity of Aberdeen. Institute of Medical Sociology. 1974 (Occasional Paper. No. 1 ). pp. 57. This report discusses data from the early 1970s on teenage sexual activity in a cross-cultural perspective. More important studies arc quoted and data placed in a sociocultural context. Johnston, J. A. Reachiny 0111-0/-sclwo/ r0111h: a projec1 p/a1111iny lwndhook ji1r pop11/(l/ion)m11ih life ed11ca1io11. London. International Planned Parenthood Federation. 1975. pp . 75. This book prm ides guidelines for family planning and sex education programmes for out-of-school youth. Headings are: setting objecti,es. identification of target groups. deciding content. planning programme communication. planning programme resources. and planning pro- gramme e,aluation. The book also contains a section on pilot projects in population-family life education. Kozakiewicz, M., ed. Sex - socielr cdu('{i/io11 : Polish experience. Warsaw. Polish Family Planning Association TP R (formerly TPR: Towarzystwo Planowia Rodziny. now TRR: Torwarzyotwo Rozwoju Rodziny). pp. J 12 . The book contains a collection of papers that were all originally published in Polish. The purpose of the book is. according to the editor. to mak e Polish experience in the field of family planning and sex education more widely known. The book is divided into three major sections: sex in changing Polish society: sex as an object of ethical reflection: education for sexual. marital. and familial life . The book ranges from problems in Polish penal law and descriptions of Polish premarital customs to detailed descriptions of sex education in Polish schools and other forms of preparation for life in the family. Of the 15 chapters seven have also been published in The sex and senlill ed11ca1io11 in Poland (see p. 120). Kozakiewicz, M. Sex cd11ca1ion and adolescence in Europe: sex11a/i1_1 ·. n,w.,-iaye and 1he ji1mi/y. London. International Planned Parenthood Federation. Europe Region. 198 I. pp. 118. This book is divided into two sections . The first compares different European approache~ to sex education. the second presents numerous data indicating changes in adolescent sexuality. Drawing on studies from most European coun tries. the author provides data on physical maturation. ma rria ge. mast urbation . petting. coitus. adolescent con- traception. abortion. and many other sexua lly-rel a ted issues . Kucera, z. Young people in the Czech Socialist Republic and their ideas on preparation for marriage. In : Zdraro1ni r_rchora. Me10dick_1 · 117 Material - Vymena Zkusenosti. Prague, Ustav Zdravotni Bychovy . 1980, pp. 2. This is a short summary in English of a Czech study on the information about sex acquired by people aged 15- 30 years. Lewers, P. & Miltner, W. Z11·ischenbericht des GRAPEVINE - Projekt Stuffgart: Berichts::eitraum April his De:emher 1979 . Frankfurt am Main , Pro Familia. Deut sche Gesellschaft fi.ir Sexualberatung und Familieplanung e.V .. 1979. pp . 22. This is a report on the adaptation of the project idea .. Grapevine" (see p. 114) to the situation in Stuttgart. The report discusses the organizational aspects of the project as well as problems encountered during the initial stages . Lewin, B., ed. Sexual affitudes and sexual experiences among teenagers in a Swedish city. Uppsala. Uppsala University, 1980, pp. 67. This book contains articles. a few in English. on the sexua l attitudes and sex ual experiences of teenagers in a Swedish city. Complete frequency tables are presented in English. Some background characteristics of school gynaecological clinic patients as compared with a representative sa mple of pupils are discussed in English. Mechler, H.-J. & Schusser, H. Model/projekt piidagoyische um/ heraterische !nt erre11tio11 in den Bereichen Sexualitiit und Fa111ilie11p/a11u11g hei Soldate11 der Bundes1rehr: Ahschlusshericht se.rnalpiidayoyische Gruppenarheit mil Offi::iersstude11te11 und ::ukti'nfiiqe Perspektiren des Projekts. Frankfurt am Main. Pro Familia. Deutsche Gesellschaft fiir Sexualberatung und Familieplanung e.V .. 1981 (Pro Familia Projektberichte. No. 8). pp. 67. Thi s contains the final report from two weekend seminars with officer ca ndidates for the German army and their spo uses as well as some additional remarks o n the project .. Educational a nd advisory family planning services for so ldiers in the German army" Paulich, P. A u.1·11 ·ert 1111ysu'richt Model/projekt Se.rnalpiidayoyik in der a11.1·serschulische11 J11ye11darheit Auyshury Miinchen. Frankfurt am Main. Pro Familia. Deut sc he Gesellschaft fi.ir Sexualberatung und Fami lieplanung e.V .. 1978 (Pro Familia Projektberichte No. 3). pp. 50. In the two German cities of Augsburg and Munich special efforts were made from 1976 to 1978 to reach adolescents with educational and advisory services. Adolescents were approached in va ri o us out-of-school set tings. Th e more important experiences and the possib le applicability of the findings in o ther se ttings are discussed. Paxman. Fertility in adolescence. law policy and ad o lescent sex ualit y. Journal of hiosocial science. Suppl. 5 ( 1978). pp . 27 . This paper considers so me of th e major legal problems associated with the regulati on of adolescent fertility . The complexity of the laws is noted I 18 and international comparisons are made. The headings are: availability of fertility-related ed ucation and information. availability of fertility- regulation services. contraception and abortion. Mohile Beratungsstelle in, ln/i1rmarionseillsa1:: Berichr iiher er.1N Er(ahrungen. Frankfurt am Main. Pro Familia. Deutsche Gesellschaft fiir Sexualberatung und Familieplanung e.V .. 1974 (Pro Familia ln fo rmat ionen 3;74). pp. 16 . This leaflet describes the ambulatory information centre of the family planning association in the Federal Republic of Germany . Jugendarbeit , Heimkinder - Heimjugendliche - Juyend::entrum und Arheits/ose Jugendliche. Frankfurt am Main. Pro Familia . Deutsche Gesellschaft fiir Sexualberatung und Familieplanung e.V .. (Pro Familia lnform ationen 3/76). pp . 40 . This leaflet reports on a number of special projects of the Family Planning Association in the Federal Republic of Germany. The purpose of all these specia l projects is to reach adolescents with educationa l and advisory services. Projekte der Pro Familia ill der Jugelldarheir . Frankfurt am Main. Deutsche Gesellschaft fiir Sexualberatung und Familieplanung. 1979 (Pro Familia ln formationen 2 79) pp. 19. This leaflet lists and comments upon recent projects that have ado lescents as specia I target groups. Das Projek t Sexualpiidagoyik ill der ausserschulischell Jugelldarheit Augshury/ Miinchen. Frankfurt am Main. Pro Familia. Deutsche Gesellschaft fiir Sexualberatung und Familieplanung e.V .. 1979 (Pro Familia lnformationen 5/79). pp. 2. This leafle t describes the specia l efforts of the Fami ly Planning Association in the Federal Republic of Germany to reach ado lescents m out-of-school se ttings in the cities of Augsburg and Munich. Mohile Berarungsstelle oder fll/omohi/e. Frankfurt am Main . Pro Familia. Deutsche Gesellschaft fur Sexualberatung und Familieplanung e.V .. 1980 (Pro Familia Information 4/80). pp. 5. This leaflet provides a brief description of the ambulatory information centre of the Family Planning Association in the Federation Republic of Germany. Puchinger, B. & Jager, E. Psychologische iiberprii/img eines TV-spots iiher Emp/angnis Verhiirunysmerhoden . Teststre{len I "coitus illter- ruptus". Vienna. bsterreichischen Gesellschaft fiir Familieplanung. no date. pp. 24. The Australian Family Planning Association has planned a se ries of TV trail ers on various contraceptive methods. The first. which dealt with coitus interruptus. was tested on pupils in two schools. After seei ng the 119 film the pupils answered a questionnaire dealing with their cognitive and emotional reactions to the film Rasmussen, N. Teen-aye .fi•l'I ili1_r and ji•l'I iii fr rey11/a1 iny pall ems in Drnnwrk . University of Copenhagen. Institute of Social Medicine. Joint Center for Studies of Health Programs. 1978 (unpublished document). pp. 12. Drawing on recent statistical data and a number of Danish studies. the author describes present fertility-regulating patterns among adolescents in Denmark. He notes that further research is essential on the problem or tran sfo rming knowledge into adequate contraceptive behaviour. Rauch, S. et al. Tatigkcit sbcricht dcr Mitarbeitcr des Modcllprojekts Mobile Bc ratungsstcllc. Frankfurt am Main. Pro Familia. Deutsche Gcscllschaft fi.ir Scxualberatung und Familieplanung c.Y .. 1978 (Pro Familia Projcktberichte. No. I). pp . 249. This is a detailed report on the ambulatory advisory clinic of the Family Planning Assoc iation in the Federal Republic of Germany. There arc sec tions on the background and organizational as well as on various naluativc aspects of the project. Thl' .\1 '_ \ · (//1(/ .\l'.\llal ed11rn1 ion i11 Poland. The no1ehook of se.nwlilr I . Rome . Bul1011i . 1977. pp . 137. This book contains a number of texts on Polish sex education and Polish premarital manners and customs . The text is in English and Ita lian. Sex education curricula arc presented for various school levels . Scxualpadagogischc Fortbildung fi.ir Mitarbcitcr dcr ausscrschulischcn Jugendarbcit. Modellcntwurf dcr Pro Familia Saarbri.ickcn. Snua/piidayoyik. No. 4 (1978) . This article comments on the need for the continuing education of those who work with out-of-school youth . Objectives for such education arc proposed and a number of suggestions derived from earlier projects of Pro Familia arc made . Scxualpadagogisches Team Pro Familia Saarbri.ickcn . Auswer111114s- herich1 Medel/projekl sex1wlp1ida404ische For1hild11nq fiir Mitarheiler in da 1111.1s1' r.1clt11/isclw11 J11y e111/arhei1. Frankfurt am Main . Pro Familia. Deutsche Gesclbchaft flir Scxualhcratung und Familie- planung. 1981 (Pro Familia Projcktbcrichtc . No. 7). pp. 68 . This document contains a detailed report on a project dealing with continuing education for those who work with out-of-school youth. S1a1e111c'1tl on adole.1"Cen1 ji·r1ili1r. London. International Planned Parenthood Federation. Central Medical Committee. Law Panel and Management and Planning Committee. 1977. pp. 4. This statement considers adolescent fertility. its psychosocial con- sequences. its health implications. and its legal aspects. 120 Sundstrom, K. Young people 's sexual habits in today 's Sll'edish society. Stockholm, The Swedish Institute, 1976 (Current Sll'eden, No. 125), pp. 8. In this paper adolescent sexuality is discussed mainly in terms of teenage pregnancies. A surrey on the status of sex education in European memher countries. London. International Planned Parenthood Federation. Europe Region, 1975. pp. 89. This book presents comparative data on sex education in Austria, Belgium. Denmark , Finland. France. the German Democratic Republic, the Federal Republic of Germany. Italy, Luxembourg, the Netherlands, Norway. Poland, Portugal. Sweden. Turkey. the United Kingdom, and Yugoslavia. The book is divided into two parts. the first dealing with a number of issues that are discussed one by one and the countries compared with each other. the second containing reports on the status of sex education in each country. Trost, J. Some notes on adolescent ./£'rtility hehariour in S1rede11. Uppsala University. Depart of Sociology. 1978 (unpublished docu- ment). pp. I 0. This is a short historical outline of family planning and sex education in Sweden. Contemporary adolescent sexual behaviour is discussed on the basis of recent data on adolescent fertility and abortion. OTHER RELEVANT MATERIAL United Nations and specialized agencies The child and the adolescent in society: report on a WHO conference. Athens 26- 30 September 1978 . Copenhagen. WHO Regional Office for Europe. 1979 (EURO Reports and Studies. No. 3). pp . 60. This report discusses the characteristics of the various age groups in childhood and adolescence . their biological problems. and their psychosocial problems and their solution in terms of research . health services. health education (including education on sexuality) . general services. and manpower training. WHO Technical Report Series. No. 613. 1977 (Child mental healrh and p.,ychosociul daelopmenr : report of a WHO Expert Committee). pp . 72. In this report. the current situation is discussed and opportunities for action identified. Among possibilities a number of preventive measures are suggested and research implications and priorities discussed. Recommendations deal with prevention. treatment. the identification of mental disorders in children. planning and coordination programmes. and the training of health personnel. 121 Co-ordinated Action Programme for the Adrnncement of Population Education ( CAPAPE ). Socio-cultural case studies for population education. Fundamental concepts and methodology, research outline. Paris, UNESCO. Population Education Section, 1978 (UNESCO ED 79 /WS/24). pp. 91. The UN ESCO General Conference at its Fifteenth Session in I 968 entrusted the Secretariat with the task of developing a population programme in three sectors of the Organization: education, social sciences, and communication. Within this structure. the education programme has implemented and coordinated a large number of projects. The purpose of these studies is to elaborate education programmes and this research outline deals with fundamental concepts and methodology. Co-ordinated Action Programme for the Adrancement o/ Population Education ( CAPAPE) . Study on the contribution o/ population educa tion to educational renewal and innomtion in El Salvador, The Republic ol Korea, the Philippines and Tunisia . Paris, UNESCO, Population Education Section , I 980. pp. 207. This study (also in French and Spanish) emphasizes pedagogical innovations thought to be of interest in both formal and non-formal education. It contains detailed descriptions of programmes in the countries mentioned. Edstrom, K. Reproductire health in adolescence: an overview. Geneva, World Health Organization. (unpublished document), pp . 34. This document states that the attainment of sexual maturity opens the door to reproductive behaviour, but that the first few years after the onset of fertility are not optimal for healthy reproduction or for the wellbeing of the child. It also claims that reproductive events during the teens represent a portion of overall fertility that must not be considered insignificant and is quantitatively increasingly important in many of the developing countries. The effective provision of contraceptive services to young people is believed to be difficult and improvements will have to include a change in the attitudes of policy-makers. service providers , and others. Family health and family planning. A collection of papers published under the sponsorship of the WHO Regional Office for Europe and the International· Children's Centre. Copenhagen, WHO Regional Office for Europe. pp. 333. This collection of papers. which is also available in French. is largely made up of some of the papers distributed to participants at the courses on family health and family planning that have been organized every year since 1973 by the International Children's Centre and the WHO Regional Office for Europe. The volume contains a chapter by Professor Deschamps on pregnancy and contraception in adolescence, and another by Professor Dierkens on sex education. Several authors discuss 122 integration and the evaluation of family planning. Most contributions are written in a textbook-like manner and are usually quite informative. Fllmily li/'i- educlltion llnd serrices llrnilllhle to adolc'scents: a cross- cultural suney. Geneva. World Health Organization . 1980 (un- published document MCH 80.1 ). pp . 45 . To obtain information about family life education and se rvices to adolescents in difTerent countries. WHO in collaboration with the IPPF conducted a cross-cultural study intended as a first step towards ascertaining th e particular needs and problems of adolescents in different parts of the world. So that the information reflects the situation in a cross-cultural context. it was decided to select a number of individuals in difTerent countries and ask them about the availabi lit y of fami ly life education materials and services for adolesce nt s in their own countries. Country profiles arc presented for Czechoslovakia. Ghana. Hong Kong. Indonesia. It a ly. Mexico. New Zealand. Senegal. Thailand. Turkey. and the United Kingdom . Special area profiles are available for Bombay in India . Trieste in It aly. Wellington in New Zealand. Exeter in the United Kingdom. and California. Colorado. Illinois. and Pennsylvania in the United States . WHO Technical Report Series. No. 609. 1977 (Health needs of adolescents: report of a WHO Expert Committee). pp . 54. In this report the period of adolescence is discussed as one of transition from childhood to adulthood . Attention 1s given to the basic physiological and psychosoc ial needs of ado lescents in general as well as to the specia l health needs of particular groups such as migrants and the handicapped . The organization of health care fo r adolescen ts is discussed and a number of recommendations are made. The report concludes. inter lllill. that .. in view of the recognized risk of pregnancy in early adolescence. family life education. including educa ti on in responsible parenthood and sex education. should be started at an appropriately early stage and continue in the family and the school with the active involvement of parents." ln ji,rnwtion note 011 the project lwndhook ./<Jr teacher trninin!J in population ed11catio11.fa111ily lifi' education sex edurntion r POFASED ): a resrnrch proic'ct. Paris. UNESCO. Population Education Section. 1979. pp . 5. There is a growing desire in almost all countries for restructuring educational systems. This information note contains a short presentation of the working programme for the preparation of a handbook . The preparation will involve lid hoc working groups. studies. workshops. and the drafting and testing of a provisional handbook. Mace, D. R., Bannermann, R. H. 0. & Burton, J. The teachiny o( human sexuality in schools for health pro/i'ssionals. Geneva. World Hea lth Organization. 1974 (Public Health Papers. No . 57). pp. 47 . 123 This volume is concerned with the teaching of educators. Although not dealing with adolescence. it has been included in this bibliography since it makes many suggestions on educational programmes for educators. A chapter is also devoted to means of starting new programmes. An outline of a curriculum content for the training of sex educators is given in an annex. Mee1i11y 011 research needs in rela1io11 lo reproduclire heal!h i11 adolescence i11 some cou111ries o/ 1he Wes/em Pacific Rey ion co11rened hy 1he WHO Reyional Office for !he Wes/em Pacific. Kuching. Sarawak. Malaysia. 11 - 16 June 1979. Manila, WHO Regional Office for the Western Pacific. 1980 (unpublished document (WP)MCH 1M3/7617). pp . 25. The special problems of adolescents are stated in this report to be both medical and social. Physically. pregnancy in young adolescent girls poses problems- the younger the girl the more serious the problems. The problems include a greater risk of premature birth . stillbirth. a low birth- weight. and complications at delivery . But the use of contraception also poses problems: the effects of hormonal contraception in this age group are uncertain: the IUD causes considerable problems for the nulliparous: and the rhythm method is unpractical because of the irregularity of menstrual periods . Research approaches and needs are discussed against this background. The discussion is followed by descriptions and discussions of the particular research needs of Fiji. Malaysia. the Republic of Korea. Sarawak. and Singapore . Populalion educalion : a contemporary concern. Paris. UNESCO, 1978 (Educational Studies and Documents, No 28). pp. 20. This publication. also published in French and Spanish. gives the results of a study on the fundamental concepts and the methodology of population education. Special reference is made to the problem of implementing school and out-of-school programmes. Regional Workiny Group on Health Needs or Adolescenls , Ma11ila. Philippines, 12- /8 March /980: final report. Manila. WHO Regional Office for the Western Pacific. 1980. pp . 30. This report identifies a number of major issues in adolescent health. among them risk-taking behaviour and sexually related problems . Education and training are discussed , and a number of general conclusions are reached and recommendations made. One conclusion is that there is an urgent need for the development of programmes and services accessible to adolescents and geared towards preparation for and postponement of parenthood. Reproductii-e heal!h of adolescents in some countries or the South-Ea.1·1 Asia Region of WHO : report of a meeting held at Ba11gkok 011 28 July - 2 August /98/. New Delhi, WHO Regional Office for South-East Asia. 1981 (unpublished document SEA /MCH / 142). pp . 42 . 124 This report contains country reviews that identify the problems. action programmes. and research needs of the countries of the WHO South- East Asia Region . Research methodology issues are also discussed and specific research strategics identified . Country-specific research and action plans arc presented for Bangladesh . India. Indonesia . Sri Lanka. and Thailand . Wor/.:iny yroup 011 11dolc.1"C1'11/ ji ,r1ili1r 111mwycmc111 . Manila. 13 - 17 Oc1ohcr /1)80: final report . Manila . WHO Regional Office for the Western Pacific. 1980. pp . 42 . In this report the period of adolescence is reviewed and the experience of countries summarized. The main issues in adolescent fertility manage- ment arc discussed. research need s identified. and health and health- related scn·iccs considered . The conclusion is that ··the inappropriateness for adolescents of approaches and programmes developed for adults is re0ectcd particularly in the area of fertility regulation . . . In order to better meet the service needs. attention should be given to the specific and appropriate training of all categories of service personnel dea ling with adolescen b. •• Material other than from the United Nations and specialized agencies Adolc.1-c1'11/s and ji•r1ilitr pla1111i11y: a research rffinr and hihlioyraphr. London . International Planned Parenthood Federation. 1979 (Research for Action . No. 5). pp. 79. This book is divided into two parts. The first consists of five chapters: formal research and youth: adaptive family groups: problems in education and communication: implications for research : and impli- cations for programmes . The second consists of an annotated bib- liography of adolescent fertility and adolescent fertility planning. Most of the works listed are from developing countries o r deal with matters relevant to developing countries. Byrne, D. Sex without contraception. /11: Byrne. D. & Fisher. W. A. ed. Adolescents, sex. and contraception. New York. McGraw-Hill . 1983. pp. 52. The theme is that in most industrialized nations sex ual attitudes and sexual practices have undergone astonishing changes . The simple biological union of sperm and ovum can lead to the profound joy of deliberate parenthood. but also to the anguish of an unwanted pregnancy. A theoretical model is presented in order to facilitate the understanding of the psychological determinants of contraceptive behaviour. Duprcz, L. Final report on the Third Seminar on Sex Education and Social Derelopment, Stockholm, 14 March - 4 April /976. Stockholm. Swedish International Development Authority . Division for Population, Health and Nutrition. 1976. pp. 231. 125 The seminar included representatives of 13 Latin American countries and four Caribbean countries. The United Nations Fund for Popula tion Activities. the World Council of Churches. and the IPPF Middle East and North Africa Region. and Western Hemisphere Region and West Africa were represented by observers. The main focus of the seminar was on sex education and social development in the participating countries. Swedish experience provided part of the background for discuss ions on how the problems could be tackled in Lat in America and the Caribbean. The book contains a number of papers on Swedish experic:,ce. as well as the individual experience of lesbian s. transvestites. and tran ssex ual s. There are basic guidelines for a course in sex education. and papers on the fi e ld of action of and required training for sex educators. education for sex affirmation. sex uality and love. and the requirement s for a sex educator. Finkel, M. L. & Finkel, D. J. Sexual and contraceptive knowledge. attitudes and behaviour of male adolescents. Family planniny perspectires. 7: No . 6 (1975). pp. 5. This article presents the result s of a su rvey of 421 mal e students at three high school s in a large city in the north-eastern United States. At their latest intercourse. 55 °., of the boys used no contraceptives or relied on withdrawal or their pa rtners douching . H a lf of the sexually experienced boys had begun sexual activity before the age of 13 . In view of these and related findings. the a uthors hold that sex education programmes ofTered in high schools are too late . Sex education should. it is argued. be ofTered in junior high school and birth control programmes be extended to younger male as well as to female ad olescent s. Holmstedt, M ., ed. Second Seminar on Sex Education and Social Dal'lopmi'nt in Sweden . Latin America and th e Carihhean. April 1972 . Stockholm. Swedish International Development Authority. Populatio n Divisio n. 1974. pp . 280. Thirty participants from 17 difTerent Latin America n countries. and observers from UNESCO. WCC. IPPF. and WHO attended. The seminar consisted of lectures. demonstrations of materials . case-work. discussions. and group work. The following subjects were dealt with: Swedish development in socia l welfare . education. and sex education: the present situation in difTerent Swedish educational sys tem s: sex education methods: teacher training and audiovisual aids: medical care and sociopsychological aspects (general roles. attitude research . mass media. etc.): and Swedish and international family planning and sex education projects . Nazer, I. R .. ed. Sex educa tion in schools: proceedin4s of 1111 1'.Yf11'rf yroup /l/1'1'till!I IPPF Middle East and /Vorth Africa Reywn. Bein// . Dffe111her /974. Carthage. International Planned Parenthood Federation. Middle East and North Africa Regi o n. 1976. pp . 1.37 . In thi s \·o lume sex education in sc hools is discussed from a number of 126 viewpoints . The book is di\'ided into se\en ,cctions : ge nera l background : introducti o n to sex education : the role of the media in sex educa ti o n: th e role of famil y pl a nnin g associations and schoob in sex educa ti on: the need fo r sex educati on in the IPPF Middle East a nd Africa Region : regional experience of sex ed ucation : a summary of the di sc uss ion , . Neither the material prese nted nor the di,cussion is restricted to the Middle Eas t. In th e introduction to sex educatio n the experience of Poland . Sv.-cdcn . and the U nit ed Kin gdom is presented . Thi' fll'l'r oppro11ch l o .11'. \1111/i/\' £'d11cu1ion: 11 y11idl' w 11ro11n1111 impll't11£'11/ol io11. Washin gton. DC. Int erna ti ona l Clearingho use on Adolescent Fertility. Cen te r for Popul a ti on Options. 198 1. pp . 16. This sho rt guide descri bes model programmes from \ a ri o us parts of the world and discusses a number of i~s ues for consideration in trying to impleme nt a pee r-gro up p rogra mme . Fairly detailed descriptions arc g iven of model progra mmes in Bangladesh. the Philippines. the U nited Sta tes o f Ame rica a nd Ur uguay . Shorter descriptions and contact addresses arc g iven for a p rogramme in Africa . four programmes in A sia. a programme in the Cari bbea n. two program mes in Latin America . and two programmes in North America. The following issues arc discussed: goa ls. pee r education vers us peer co un se llin g. role o f the trainer. participant se lecti o n. parental invo l\'cmcnt. a nd funding. There is a sh o rt annotated bibliography . Ratnam , S . S .. ed. A d o le.\'C£'11l .1'£' .rnolity. Singapore. Family Plannin g Assoc iation of Sin gapore. 1979. pp . 66. The papers in thi s vo lume were presented at a seminar held in Singapore in August 1978. The o bjecti ves were: to increase awareness among profess ional s working with adolescent s o f needs and iss ues related to ado lescent sex ualit y: to facilitate the exchange of knowledge and experience among the pa rticipa nt s: a nd to stimulate pa rticipant s to establish a ppropri a te se rvices fo r adolescents to prepare them for respon sible sex ua lit y a nd respo nsible parenth ood . S tella, R. M. lncreasiny you//, programmes in family planning. Kua la Lumpur. Intern a tio na l Planned Pa renthood Federation. Ea st and South-East Asia and Oceania Region . 1975 (IPPF-EASOR Mon ogra ph. No . 5) . The background to the growing recognition of the needs and concerns of yout h is sketched and short hi story given of the International Planned Pa renthood Federa tion and it s in vo lvement in family planning for adolescents . DifTerent a pproaches to youth progra mmes are discussed with particular reference to the countries in the East and South-East Asia and Oceania Region of the IPPF. Voss, J. R . Sex education: eva luation and recommendation s for future stud y. A rehires of sexual heharior. 9. No. I (1980) . pp. I 3. This article briefly out lines the rationale for and the goals and scope of 127 sex education programmes. and reviews research on their efTectiveness. The majority of the programme evaluation studies in sex education sufTer. according to the author. from poor research design . However. the information available largely supports the view that sex education can produce certain beneficial results. specially in relation to attitude. experience. and knowledge . In her recommendations for future research the author stresses the need for a more rigorous evaluation of outcome. a long-term follow-up . comparison of difTerent methods. and more detailed subjective evaluations . Most of the material discussed originates from the United States of America . The youth rnlucs project . Washington. Population Institute. 1978. pp. 68. The Youth Values ·Project. a study of adolescent sexuality conducted by teenagers themselves. began in 1976 to explore the reasons why sexually active teenagers in New York City to not employ birth-control methods. A diverse group of teenagers were hired to develop and administer a confidential questionnaire to their peers. They also analysed the results and conducted peer sex education sessions. The sample population of persons aged U 19 included every ethnic and income group. Only 26°,, of the females and I I 0 ,, of the males reported that they always used birth control. When asked whether birth control was available to them without problems. 11 °,, said "No". 43 °,, said "Yes". and 46 ",, said "I don't know". Only 28 °,, of the respondents knew when conception was possible. although 67 °,, of the active females and 53 °,, of the active males said they knew enough about birth control. OTHER MATERIAL l 'nited Nations and specialized agencies Bihlioyrnphr 011 h11111e111 l"t'produc1io11 . .fwnilr p/a1111i11q and pop11/a1io11 dr11a111ics 1//1110l//ll'II or1icll's 011d 1111p11h/ishl'd 11·ork in lhl' S01ilh-Eas1 A.,io Rl'yiun New Delhi . WHO Regional Office for South-East Asia . A number of bibliographies were published during the 1970s under this title . There ha\·e been SC\"Cral issues yearly . supplemented by special issues dcrntcd to particular fields of study . Under the headings Family planning within community health Family health and family planning programmes . with \arious subheadings. material can be found relevant to sex education and family planning for the young . Unfortunately there has ne\·er been any particular heading (or subheading) under which material relnant to young people could be found. The headings also \ary somewhat o\·cr time and the bibliography leans more towards technical medical issues than towards issues like family planning policies . WHO Technical Report Series. No . 569. 1975 (Ern/1101iu11 of .fa111ilr p/01111i11y in ht ·ol!h .1t' 1Ticl's: report of a WHO Expert Committee). pp 67 . 128 This is a guide to the evaluation of family planning services in general and is not specially geared to the evaluation of family planning services for adolescents. However, it could be very useful in evaluating family planning projects for young people. Concepts and definitions are given, current practices in the evaluation of family planning discussed, and guidelines for the evaluation of family planning presented. There is also a discussion on selected measures that might be useful. Family health and family planning bibliographic bulletin. Published jointly by the International Children's Centre and the WHO Regional Office for Europe. 1979. This bilingual publication (references and annotations in French as well as English) contains 117 references to recent publications in the field of family health and family planning. Six of these references are found under the heading "Young people and family planning". Ryde-B/omqi·ist , E. Contraception in adolescence- a rerie1-r of the literature. Geneva, World Health Organization . I 975 (unpublished document MCH /75. 1 ), pp. 27. This review is divided into the following sections: social aspects; sexual attitudes and behaviour; sex education and information ; contraceptive services for adolescents; medical and clinical aspects: and legislation . Almost a hundred different sources are quoted . Material other than from the United Nations and specialized agencies Adolescent fertility. London, International Planned Parenthood Federation , 1977 (IPPF Bibliography Series. No. 45), pp. 28. This bibliography is based on the holdings of the IPPF library and documentation service. The 131 references are organized under the headings: general situation; sex ual maturation; adolescent sexual be- haviour; adolescent pregnancy; contraception for adolescents; abortion in adolescence; services for adolescents; unmet needs; legal aspects. Eighty- three of the references have been assigned to specific geographical areas, including seven to Africa, Seven to Asia, 14 to Europe. one to the Middle East, 43 to the United States of America , and 11 to the rest of the Americas . Approaches to population mrnreness. fami/r life and sex education for young people: selected resource materials . London, International Planned Parenthood Federation. 1978 . In this booklet the selected resource materials listed and presented are organized under the headings: out-of-school educational approaches: participation by youth: education for population awareness: family life education: sex education. The booklet also contains useful contact addresses of various organizations active in the field of family planning and sex education. 129 Bell, J. & Billington, D. R. Annotated hihlioyraph1· of health education research completed in Briwin _Ii-om 1948- /978. Scottish Health Education Unit. This bibliography contains a section on sex education in which 17 works are presented. For each entry, the aims. methods. and results are presented. CBGS annual rerort 1979. Brussels. Ministry of Public Health and the Family, Population and Family Study Centre, pp. 184. This annual report contains descriptions of ongoing research projects. presented under the headings: population studies in general: regional demographic studies: studies on partner relations: studies on family planning and parenthood: studies on the living conditions of the family: studies on aging and the aged: studies on education and welfare . Dogget, M.-A. Selectire hihliowaph_1· on sex edurntion. 1970- 1980. British Pregnancy Advisory Service, 1980 (unpublished document). This selective bibliography contains 42 references and is not annotated . The references are organized under the headings: general trends: morality, rights and responsibilities: definitions and objectives: percep- tions and effects: teaching and evaluation: materials. Illsley, R. Research on adolesce/1/ preynancy in the United Kinydom . Aberdeen. Institute of Medical Sociology, MRC Medical Sociology Uni t, (unpublished document). pp. 6. This paper comments on a few of the more recent studies conducted in the United Kingdom . and gives an idea of the present state of research. International 1rnmen and health resource guide. Carouge, ISIS and the Boston Women's Health Book Collective, 1980. pp. 178. This guide is primarily an annotated resource list, including introductory comments and long and short excerpts about women and health from a number of sources . The publication is multilingual, giving headings. etc . in English . French, German. Italian , and Spanish. Whenever possible the inclusion of an item means that the following information is given: title. author , source (book. journal, publisher). publication number and date (if a journal), ordering address. publication date (if a book). and price. The resource material is presented under the following headings: basic international resource list: women's ro le in health: reproductive issues: drugs and drug companies: food and eating: having children: menopause and aging: our health and our environment; self-help and healing ourselves: audiovisuals: listings by region /country. lnrentory of research in progress of the International Clearinghouse on Adolescent Fertility. Washington. International Clearinghouse on Adolescent Fertility. Center for Population Options. 1981, pp. 67. The inventory offers brief descriptions of a number of research projects related to adolescent fertility. Seven of the projects are in Africa or the 130 Middle East, I 8 in Asia, two in the Caribbean, 7 in Europe, 11 in Latin America, a nd 22 in North America. The types of research vary from studies on macro patterns to attitudinal studies of schoolchildren . The emphasis is on medically related studies, although some studies may be of interest for service implementation. For each study the title of the project. the name of the principal investigator, and a short description of the research are given , as well as the funding sources. which vary from friends to international organizations. this suggesting the heterogeneity of the research projects in the catalogue. Les jeunes er la sexualire- Enqueres recenres. Paris. Conseil supeneur de l'lnformation sexuelle , de la Regulation des Naissances et de !'Education familiale, 1980, pp. 2. Thi s sheet contains references to eight recent studies on adolescence and sexuality. Van Damme, J . & Presvelou, C. La sociologie de la sexualire: Tendances de la recherche er hihliographie annoree /965 - /975 . Louvain-la-Neuve. Universite Catholique de Louvain , lnstitut des Sciences familiales et sexologiques, 1978, pp. 212. This book consists of two parts. the first a study of tendencies in sociological research on sexual matters. the second an annotated bibliography. References are organized under the following headings: sexualite. sexologie et societe: developpement social sexuel. education, information et roles sex uels: heterosexualite: attitudes et comportements: homosexualite: attitudes et comportements. For each entry the following information is usually given : a short description of the study. objectives, limitations. etc. : the basis of the study. e.g. , questionnaires: the type of stud y, e.g .. descriptive, theoretical. empirical. 131 Annex 2 QUESTIONNAIRE TO ALL GOVERNMENTS OF MEMBER STATES OF THE WHO EUROPEAN REGION Please read this before answering the questionnaire The Regional Office for Europe of the World Health Organization is presently studying family planning and sex education of young people . The objective of the study is threefold: - to acquire a more comprehensive knowledge about earlier studies and evaluations of various programmes of sex and family living education as well as family planning programmes for young people: - to identify various government policies regarding family planning and sex education of young people: - to identify various strategies adopted and problems encountered when working in the field of family planning and sex education of young people. It is the intention of the World Health Organization to publish, at a later date, guidelines for family planning and sex education of young people. Such guidelines have to be based on an accurate knowledge of the situation in a number of countries, since traditions and cultural values differ markedly between countries in the WHO European Region. In fact , data is to be gathered from all countries in the Region concerning government policies . We are aware of your interest in this field and are therefore asking for your assistance in our efTmt to identify the government policy of your country. You are asked to answer this questionnaire in order to help us identify the official policy of your country. You are not asked to give your personal opinion but to quote the official opinion. In some instances interpretations of official documents and policies may be necessary so that the official policy can be clearly stated. We are, however, convinced that you are in a position to make such interpretations of the official policy . Since you are the only person in your country to whom these questions are put , your cooperation is essential for the success of the study. Although we ask you to answer. you are of course free to consult others if you are uncertain about some matters . Most questions can be answered simply by making an X in a box . Only in a few instances are you asked to fill in an answer in your own words. Please read the instructions carefully and do not rush. It will 132 only take a very limited amount of time to complete the questionnaire even when you work very carefully. This questionnaire might seem to be quite long. Such an impression is however not entirely correct si nce no one has to answer all questions. In several instances you are asked to pass a number of questions as a result of previous answers. Some questions might seem very awkward to you. Please try then to remember that the same questionnaire is used in all countries of the WHO European Region. i.e. from the Scandinavian countries in the north to North African countries in the south and from Atlantic islands in the west to the Soviet Union in the east. Please do not hesitate to contact me if you have any queries. You can contact me at either of the addresses below: The World Health Organization. Regional Office for Europe. 8 Scherfigsvej DK -2 100 Cophenhagen 0. Denmark Uppsala University. Department of Sociology. Hirnvagspromenaden I 9. S· 753 20 Uppsala. Sll'eden. phone 00946 - (0) 18 14 80 67. We thank you in advance for your kind cooperation and trust you will not forget to return this questionnaire as soon as possible and at the latest before the end of October. Definition of terms Throughout the questionnaire two terms are used that might cause some confusion unless you read the following. The term YOUNG PEOPLE may seem very vague and ambiguous. This is. however. at least partially intended. Due to cultural differences between the countries in the Region, the age of the people referred to might differ from one country to another. YOUNG PEOPLE should here he understood as children and adolescents helo1r the age 1rhen people in your country usually marry or start to cohabit under marriage-like cone/it ions . The term SEX EDUCATION may also, due to the clutural differences within the Region. be ambiguous. In some cases educational programmes of the type to be discussed are called "health and sex education". Other terms known to be used are "sex and family living" . "study of sex and living together". "preparation for parenthood" . "humanization of the relations between the sexes". SEX EDUCATION is here to be understood as education that centres on human sexuality. human sexual behariour, family planning and social aspects of human sexuality. The term FAMILY PLANNING may also. due to the cultural differences within the Region, seem ambiguous. In some countries this term applies only to clinical services. whereas in other countries various counselling and advisory services are included when the term is used. 133 FAMILY PLANNING is 10 he under.1·1ood here as adrisory and counselling serrices rela1ed lo human sexualily as 11 ·e ll as clinical contraceplire serrice. * * * I. What is the legal status of sex educa1ion of' rouny people in your country? a ( ) Prohibited b ( ) Not regulated by c ( ) Mandatory (e.g . QUESTION 5 law PLEASE PASS TO QUESTION 8 compulsory in school) PLEASE PASS IF SEX EDUCATION OF YOUNG PEOPLE IS PROHIBITED TO 2. Are there presently . to yo ur knowledge. in spite of the legal problems involved any programmes of sex education of young people? ( ) No. there are no such programmes known to me ( ) Yes . there are such programmes in spite of the legal difficulties 3. Has there earlier. to your knowledge. in spite of the legal difficulties involved been any sex education programmes for young people? ( ) No ( ) Yes 4. Has anyone during the last ten years. to your knowledge. been prosecuted for giving sex education to young people '' () No ( ) Yes. please give details (e .g. when. where. who. court decision etc.) PLEASE PASS TO QUESTION 9 IF SEX EDUCATION OF YOUNG PEOPLE IS MANDATORY 5. Which institutions are supposed to convey formal sex education? ) Preschool YOU MAY CHECK MORE THAN ONE ALTERNATIVE ) Primary school. Please specify age of pupils : -----years Secondary sc hool. Pl ease specify age of pupils: ------years The Army Other school. Pl ease specify: Other orga ni1ations or institutions. Please specify: 6. Is it possible for local (municipal) governments to decide not to have sex education for young people in spite of sex education being compulsory in principle 'l ( ) No. education is always compulsory ( ) Yes. education is at the discretion of local gowrnment 134 7. Wh o decides what is to be taught in formal sex educa ti on of young people'.' Th e cu rriculum is decided by ( ) govern ment o r national board or ge neral directorate of education health ( ) loca l (municipal) govern ment ( ) local school (headmaster. teac her) ( ) o th er. please spec ify :_ IF SEX EDUCATIO IS LEGAL BU T NOT CO MP U LSORY (QUEST IO ANSWER E D WITH ALTERNATIVE B) : 8. Can loca l (munic ipal) govern ment s make ,ex education co mpul so ry for yo un g peo ple e\ en if it is not com pulsor) by national law 0 ( ) No ( ) Yes IF YES: Do yo u kn ow of any cases where a local govern ment has decided to mak e sex education compulsory for young people although it is not co mpul so ry na ti o nwid e 0 ( ) No. to my kn owledge th a t has never happened ( ) Yes . Please give details (w here . when. rationale etc . ) ALL: 9 . Which institutions organiza ti o ns ofTe r fo rm a l sex ed uca tion to you ng people and is the education special ly direc ted to wards yo ung people 0 PLEASE MAKE A CHECK FOR EAC H INSTIT UTION ORGANIZATION Special You ng People No sex p rogramme welcome to Join education for you ng programme prim ari ly available to peopk intcnd.:d for adult, yo ung people Preschool ( ) ( ) ( ) Primary sc hoo l. Age of pupil s ( ) ( ) ( ) Second a ry sc ho ol. Age of pupil s ( ) ( ) ( ) The army ( ) ( ) ( ) Fa mily planning associati o n ( ) ( ) ( ) Student organization ( ) ( ) ( ) Church ( ) ( ) ( ) Wo men 's movement ( ) ( ) ( ) Other government insti- tution s. please specify : ( ) ( ) ( ) ( ) ( ) ( ) Other voluntary organi- za tion s. please specify : ( ) ( ) ( ) ( ) ( ) ( ) 135 What is the legal status of family planning for young people in your country? 10. Is public information legal? a ( ) To advertise contraceptives and to inform about contraceptives is prohibited by law b ( ) To advertise to young people and to inform young people about contraceptives is prohibited by law c ( ) There are no legal obstacles to free information about contraception 11 . Is the sale and spread of contraceptives legal? a ( ) Sale and spread of contraceptives is not legal b ( ) Sale and spread of contraceptives is subject to special regulations to the effect that all contraceptives have to be prescribed by medical staff c ( ) Sale and spread of contraceptives is subject to regulations to the effect that some contraceptives (like the pill and IUDs) have to be prescribed by medical staff. whereas other contraceptives (like the condom) can be sold directly to the general public 12 . Are family planning services for young people legal ? a ( ) Medical staff offering family planning services are by law forbidden to assist young people with contraception b ( ) Medical staff offering family planning services are free to assist young people with contraception but must if the client is a minor take special steps (like informing parents or the client's usual physician) c ( ) There are no legal obstacles to the unlimited use of family planning serYices by young people IF THERE ARE NO OBSTACLES TO THE USE OF FAMILY PLANNING BY YOUNG PEOPLE (QUESTIONS 10. 11 AND 12 ALL ANSWERED WITH ALTERNATIVE C). PLEASE PASS TO QUESTION 16. IF THERE IS ANY OBSTACLE TO THE USE OF FAMILY PLANNING BY YOUNG PEOPLE (i e ANY OF QUESTIONS 10. 11 or 12 ANSWERED WITH ALTERNATIVE A OR B) 13. Ar;: there. to your knowledge. in spite of the legal difficulties involved any family planning counselling programmes or centres for young people? ) No. there are no such programmes kn o wn to me ) Yes. there arc family planning counselling centres that in spite of the lcga I problems assist young people 14. To your knowledge. has there in spite of the legal problems involved. pre,·iously existed any family planning counselling programmes or centres for young people although these se rvices arc not available now ? No ) Yes 15 . Has anyone during the la st ten years. to your knowledge. been prosecuted for gi,·ing family planning serYices to young people? No Yes . Please give details (e.g. when. where. who. court decisions etc.) - ---------- - - - ------------ 136 PLEASE PASS TO QUESTION 17 IF THERE ARE NO LEGAL OBSTACLES TO THE USE OF FAMILY PLANNING BY YOUNG PEOPLE (QUESTIONS 10, 11 AND 12 ALL ANSWERED WITH ALTERNATIVE C): 16. Can local (municipal) gove rnment s prohibit family planning cen tres or progra mm es fo r yo un g people eve n if there is no na ti ona l law aga inst it? No Yes IF YES: H as it eve r happened , accordin g to your knowledge, that a loca l government has prohibited a fa mil y pla nnin g centre or program me a lthough there is no national law agai nst it? No . to my knowledge that has never happened Yes. Please give details (w here. when . ra ti onale etc .) ALL: 17. Which in stitut ions organiza tions a re offe rin g fa mil y pl annin g/counselling se rvices a nd a re there any special program mes o r clinics for yo ung peo ple? PLEASE MAK E A CHEC K FO R EAC H INSTIT UTION ORGANIZATION Sch ool Student o rga niza ti o n Fami ly planning association G ove rnm ent hospit a ls Pri va te hospita ls Women's movement C hurch Other gove rnment instituti ons, please spec ify: Other volunt ary o rga niz- a ti o ns. pl ease specify : Specia l programme cl inic for young people Young People welcome to progra mme clinic primarily for adu lt s No family planning available for yo ung people 18. Are fa mily planning serrices for roung people covered by na ti onal health po licies o r ot herwi se obtai nab le a t reduced o r no cost a t a ll through gove rnment meas ures? Family pl anning se rvices fo r young people a re free of charge . whereas mos t medica l trea tm ent i not free of charge 13 7 Family planning services for young people are free of charge. like most medical treatment Family planning services for young people arc not free of charge. but are specialized subsidi7cd so that the cost is lower than for most medical treatment Family planning services for young people cost the client about as much as most medical consultations Family planning sen·ices are not available to young people 19 . Does the government (or any government institution such as national board of hea lth education or general directorate of health education) operate any family planning service for young people? YOU MAY CHECK MORE THAN ONE ALTERNATIVE No Yes. through government hospital Yes. through special government famil) planning service Yes. other . Please specify _ 20 . Does any local (municipal) go\ernment operate any family planning sen ice for young people '> ) No ) Yes . Please specify 2 1. Does the government (or any government institution) economically support a ny programme for sex ed11ca1io11 of _ro1111y people which is not operated by the government? ) No ) Yes. if possible state (in local currency) approximate value of subsidies: 22. Docs th e government (or any governmen t institution) economically support any programme or centre for fami/_r planning cm111se/li11y /i1r _ro1111y people which is not operated by the government? ) No ) Yes. if possible state (in local currency) approximate value of subsidies: 23 . Which of the following groups arc considered by the government (or ot her responsible institution handling these matters. such as the national board of health education or genera l directorate of health educa ti on) to be important target groups for family planning counselling services? 138 YOU ARE ASKED TO GIVE YOUR ANSWER BY MAKING A CHECK ON THE SCALE ON THE RIGHT OF THE GROUPS MENTIONED. CHECKING TO THE FAR RIGHT MEANS THAT THE GROUP IS CONSIDE RED VERY IMPORTANT. WHEREAS CHECKING TO THE FAR LEFT MEANS THAT THE GROUP IS NOT CONSIDERED AS IMPORTANT AS A TARGET GROUP. CH ECK I G AT INTERMEDI- ATE SCALE STEPS INDICATES I TERMEDIATE OPINIO S. PLEASE MAKE A CHECK FOR EVERY GROUP Women with many children Men with many children Married women Married men All adult women All adult men Newly-married women Newly-married men Girls just below usual age of marriage Boys just below usual age of marriage Young girls as soon as possible after menarche Young boys as soon as possible after first emission of semen 1 = Not important at all as target for family planning services 3 = Of some importance as target for family planning services 5 = Very important as target for family planning services 2 3 4 5 Is there any group you wish to add to thi s list since it is not mentioned although it is an important target group for family planning sen ices according to official policy in your country? _ _________ _ 24. Which of the following groups are considered by the government (or other responsible institution handling these matters. such as the national board of health education or general directorate of health education) to be important target groups for sex education" ONCE AGAIN PLEASE ANSWER BY MAKING A CHECK ON THE SCALE ON THE RIGHT OF THE GROUPS MENTIONED . JUST LIKE BEFORE. THE MORE IMPORTANT IT IS TO GIVE A CERTAIN GROUP SEX EDUCATION . THE FARTHER TO THE RIGHT YO CHECK. AND THE LESS IMPORTANT IT IS TO GIVE A CERTAIN GROUP SEX EDUCATION. THE FARTHER TO THE LEFT YOU CHECK . Preschool children Children in primary school Children in secondary school Adolescent girls 1 = Not important at all education 3 = Of some importance education 5 = Very important as education 2 3 as target for sex as target for sex target for sex 4 5 139 24. Contd. Adolescent boys Girl s just bel o w usual m a rriage Boys just bel ow usual marriage Newl y- married women Newly-married men age o f age of Women with many children Men with ma ny children I = Not important a t a ll as ta rget fo r sex education 3 = Of some importancc as targct for sex educa ti o n 5 = Very impo rt a nt as targe t fo r sex ed uca ti o n Is there any gro up you wish to add to this list si nce it is not mentioned a lth ough it is considered as a n impo rtant ta rge t group for sex ed ucation acco rding to offic ia l po licy in yo ur co untry'? 25 . Which of the fol lowi ng grou ps arc considered by the governmen t (or ot her respo nsi ble institution ha ndlin g these matters. such as the natio nal board of health ed uca tion or general directorate of health education) to be importan t in sex educat io n of yo un g people" Are th ere any of these themes th a t are co mpulsory and part of all curricula a nd are there any that. on the o th er hand. are considered not at a ll suitable for education of you ng people " THE MOR E IMPORTANT A THEME IS CONS ID E R ED. THE FARTHER TO THE RIGHT YOU SHULD C H EC K . THE LESS IMPORTANT A THEME IS CONS ID E R ED THE FARTHER TO THE LEFT YO U SHOULD C HECK . PLEASE ALSO INDI C AT E IF ANY OF THE TH E MES ARE CO MP ULSO RY OR ON THE OTH E R HAND. ARE CONSIDERED TOTALLY UNSU ITABLE FO R EDUCATION OF YOUNG PEOPLE Sexual anatomy of hum a ns Sex roles Parenthood Reproduc tive biology Love Psychology of pubert y Religi o us view of marriage a nd the fa mil y Pornograph y Intercourse Petting Masturbati on 140 I = Not important at all 3 = Of some importance 5 = Very importan t I 2 3 4 5 Compulsory Not fi t fo r young people 25. Contd . I = Not important a t all .1 = Of some importance: 5 = Vc:ry imp ortan t I 2 -' 4 5 Compu lsory Not fit for yo un g people Homosex ualit y Contraceptives Vene rea I diseases Sterili1ation Abo rti o n Sexual d ysfun cti ons (e .g . impo tence) Is the re any th em e yo u wis h to add to th is list which is not included. altho ugh it is a n importa nt theme according to the oflicia l policy '' 26. Wh at is the availa bilit y of various con tracep t ives for yo un g peopie 0 Easi ly Condoms Spermic ides (foam. jelly) Diaphragms Intra -uterine devices Ora l contraceptives Ho rmone lo ng-t e rm effec t contraceptives a\'ailab le Available A\'ailable in shops or other public pl aces in only whe n pharmacies prescribed wi th o ut by medical prescription s taff Not avai lab le to you ng people 27. W ha t positi o n does th e govern ment tak e to the birth rate in ) The birth ra te is too low ) The birth rate is accept able ) The birth rate is too high Not available a t al l the country? 28. What propo rti o n o f youn g peo ple leaving sc hoo l have. in yo ur opinion. received a n y formal sex educa ti on? 29 . What propo rti o n of yo un g people leaving school have. in your opi nio n. easy access to family planning se rvices? WE THANK YOU FOR YOUR KIND COOPERATION AND ASK YOU TO GO THROUGH THE QUESTIONNAIRE JUST ONCE MORE TO MAKE SURE THAT YO U HAVE ANSW E R E D ALL QUESTIONS 141 PLEASE DO NOT FORGET TO RETURN THIS QUESTIONNA IR E AS SOON AS POSSIBLE AND AT THE LATEST BY THE END OF OCTOBER . PLEASE FEEL FREE TO ADD ANY COMMENTS YOU FIND APPROPR IATE: 142 Annex 3 QUESTIONNAIRE TO SELECTED SEX EDUCATION AND/OR FAMILY PLANNING PROGRAMMES/PROJECTS FOR YOUNG PEOPLE Please read this befo~ answering the questionnaire The Regional Office for Europe of the World Health Organization 1s presently studying family planning and sex education of young people . The objective of the study is threefold : - to acquire a more comprehensive knowledge about earlier studies and evaluations of various programmes of sex and family living education as well as family planning programmes for young people: - to identify \'arious government policies regarding family planning and sex education of young people: - to identify various strategies adopted and problems encountered when working in the field of family planning and sex education of young people . It is the intention of the World Health Organization to publish. at a later date. guidelines for family planning and sex education of young people. Such guidelines have to be based on an accurate knowledge of the situation in a number of countries. since traditions and cultural values differ markedly between countries in the WHO European Region. We are aware of your involvement in this field and are therefore asking for your assistance in our effort to identify various strategies adopted and problems encountered when working in the field of family planning and /or sex education of young people. You are asked to share the experience of your work with a programme where family planning and ;or sex education of young people is of importance . This questionnaire has been sent to you . This does not mean, however, that the questions have to be answered solely by you. In some cases it is perhaps felt to be more natural that a team usually working together also answers the questionnaire together . In other cases it is perhaps the case that one person, like you. is more informed than the others. and hence better able to answer alone. Please feel free to do whichever is most convenient and natural in your own situation. In any case remember that this is not a test of your knowledge. so you are always free to consult others. Some questions might seem very awkward to you . Please try then to remember that the same questionnaire is used in many different 143 countnes or the WHO European Region. from Scandinavia in the north to North Africa in the south. Please do not hesitate to contact me if you have any queries . You can contact me at either of the addresses below: The World Health Organization . Regional Office for Europe . 8 Scherfigsvej DK-2100 Copenhagen 0. Dl'/1111ar/.: Uppsala University . Department of Sociology. Jiirnviigspromenaden I 9 . S-753 20 Uppsala . 5ll'eden. phone 00946 - (0)18 14 80 67 . We thank you in advance for you kind cooperation and trust you will not forget to return this questionnaire as soon as possible so that it reaches us before I visit you (in October - November 1981 ). Definition of terms Throughout the questionnaire two terms are used that might cause some confusion unless you read the following. The term YOUNG PEOPLE may seem very vague and ambiguous. This is. however. at least partially intended. Due to cultural differences between the countries in the Region, the age of the people referred to might differ from one country to another. YOUNG PEOPLE should here be understood as children and adolescents belo11 · the aye 11·hen people in your country usually marry or start to cohabit under marriaye-like conditions. The term SEX EDUCATION may also, due to the cultural differences within the Region , be ambiguous. In some cases educational program- mes of the type to be discussed are called "health and sex education". Other terms known to be used are "sex and family living", "study of sex and living together". SEX EDUCATION is here to be understood as education that centres on human sexuality , human sexual behariour, family planning and social aspects of human sexuality. The term FAMILY PLANNING may also, due to the cultural differences within the Region, seem ambiguous. In some countries this term applies only to clinical services, whereas in other countries various counselling and advisory services are included when the term is used. FAMILY PLANNING is to be understood here as adi·isory and counselling serrices related to human sexuality as \\'ell as clinical contraceptii-e serrice. I. Is the programme /project dealing with sex education of young people or with family planning/counselling for young people? 144 ) Neither family planning nor sex education of young people is the primary purpose of this programme/project but we deal with : ( ) Sex education of young people ( ) Family planning/counselling for young people Sex education of young people is the prima ry task . ( ) do We dea l with fa mil y pl a nnin g/coun selling fo r yo un g peo ple as well ) do no t Family planning/counselling for young peo ple is the primary task ( ) do We dea l with sex education of yo ung peo ple as well ( do not 2. Is the programme/project se t up as an ex pe rim ent o r is it of a more permanent nature? ) Thi s programme/ project ca n o n the whole be desc ribed as an experiment and unless contrary dec isions a re made the program- me/project will end on PLEASE FILL IN DATE WHEN ACTIVITIES ARE PLANNED TO CEASE This programme/project ca n o n the whole be desc ribed as an experiment and wheth er ac ti vities will continue is to be decided a t a later date which is as yet un specified . ) Thi s programme projec t is of a more permanent nature a nd will unless special decisions are taken continue indefinitely. 3. Is the programme /project being evaluated or is th ere any o th e r research carried out in connexion with the programm e project '> No evaluation o r research conducted Yes. eval ua ti on or research conducted in con nexion with program- me projec t. Pl ease specify aim of eval ua ti o n research a nd responsible resea rcher: 4 . Is you r programme project part of any o ther. more encompassing institution o r o rga ni zatio n '> N o Yes. Pl ease give name of that instituti on (in yo ur la nguage toge ther with an approximate English transla ti on) IF YES: Is yo ur progra mme project the on ly one of its kind or are th ere other programmes ,projects lik e it within the o rga ni za ti o n? The re are no o th er programmes projects lik e thi s o ne within th e organization institution There a re o the r programmes projects lik e thi s one within the o rga nization institution 5. Wh o dec ided the o bjec ti ve of the programme proiect '> Government institution . Please spec ify Vo lunt a ry orga ni zation . Please specify Other. Please spec ify 145 6. If you and your colleagues who work with this project felt that you needed to increase the stafT and wanted to employ one more person , to whom would you primarily turn to obtain necessary funds and permission? ) We would decide ourselves since we would have to raise the money ourselves We would turn to a government institution. Please specify We would turn to the local (municipal) government We would turn to the voluntary association to which we are affiliated Other. Please specify 7. Who pays for the activities of your programme1project ? Please indicate- in percentage- the financial contribution of each source. Government institutions and government Local (municipal) government Nationwide voluntary organization . Please specify Local voluntary organization Please specify Fees paid by clients Other sources Please specify 100 o·o 8. What is the tot al cost for the programme thi s yea r? Please specify in local currency 9. In some instances people who do voluntary (unpaid) work are important for programmes/projects like this, whereas in o ther instances only people who are regularly paid work with the project. Are there any people working with thi s programme/project who are not regularly paid ? ( ) No , everyone working with the programme/project is paid for her /his services . PLEASE PASS TO QUESTION 12 Yes, the programme/project utilizes the work and cooperation of people who are not regularly paid . IF THE ANSWER TO QUESTION 9 WAS YES (THERE ARE VOLUNTARY WORKERS): I 0. Are those who work with the project , although they are not regularly paid working with tasks that could bave been done by professionals or clerks? ( ) Those who do voluntary work could, in principle, just as well have been professionals or clerks 146 Those who do vo luntary work cannot be substituted with profess io nals or clerks since the voluntary wo rkers have access to groups of people th a t are difficult for pro fessionals to reac h 11 . Is the success of the programme /project dependent on the work and coopera tion of th ose who are not regularly paid? No Yes . Please specify how the success of the program me project depends on these pe rsons ALL: 12. Below yo u will find a chart in which you a re asked to fill in details concerning the staff. their tasks and employment si tuation. For example (A ) a gynaeco logi st who is a full-time employee at a loca l hospital although she works full time a t the programme project and (B) a part-time voluntary worker who is also a client could be entered as indicated below. Pos1t1on Sex o f Ta sk person (m = male. f = female) Given some finan- c1al reward A Gynaecologist Gynaecolog1cal cxam1na t1on pn manly in inserting I UDs B Voluntary m Relaying X worker information client received to friend:, Total number of persons employed Total number of voluntar) worker, doing profc»1onal or clerical tasks Total number of volun tary workers doing tasks not possible for professiona ls or clerks Employed Employer N o Yes Given Full Part no time time finan- (hours c1al per reward week) ----- X St M ary's H ospital (loca l hospit al) 147 13 . Is any kind of job rotation used? ( ) No. people have rather clear-cut areas of responsibility and are employed particularly for the task s in which they have special competence Yes. we try to encourage people to work in more than one area IF YES: Please describe how you manage this 14. How has the sta fT been recruited ? By self-selection. i.e. those initially shaping the programme project selected the first to be employed who later selected the rest of the stafT By public announcement of vacant positions and selection among candidates by a recruitment committee in which the stafT of the time was represented By appointment by the director (or equivalent) of programme Other or combination of alternatives above. Please specify 15 . If there was to be an increase in the number of people employed. by whom would the new employee be chosen ? By those presently employed and most likely among people known to those presently employed By public announcement (for instance advertisement in newspaper) that there is a vacancy followed by a selection among candidates by a recruitment committee in which the present stafT is represented By appointment by the director or board of an organization. of which the programme is part Other. please specify: 16. Is there any special target group for the activities of the programme, project ? Please indicate characteristics used to describe target group (if any) . YOU MAY CHECK MORE THAN ONE ALTERNATIVE ( ) Age. Please specify which ages ____________ _ ( ) Sex. Please specify which sex ( ) District. Please specify which district and approximate size of population in district Other. Please specify No particular target group. PL O:: ASE PASS TO QUESTION 22 IF THERE IS A SPECIAL TARGET GROUP: 17. Does the target group encompass more than young people? ( ) No ( ) Yes 18. Please quote usual description of target group 148 19. If someone who did not belong to the target group asked for the services of the programme ,project. what action would be taken? ( ) Referral of client to other institution /organization. Please specify which OfTer services just as if client had belonged to target group 20 . Please indicate what percentage of clients belong to target group ________ o 21. Has the target group described above always been considered to be of special interest for the programme/project? ALL: Yes. Which year did the programme;project start? No . Which year was the present target adopted') IF NO: Which was the previous target if any? No defi ned target earlier 22 . Is there any other agency that. at least in principle, could ofTer the same services you ofTer? ) No ) Yes. Please specify which ____ _ IF YES: What can your programme;project offer that other service providers have problems offering o r do not ofTer? 23. Have your clients received any formal sex education prior to their contact with the programme/project? A ( ) None or very few have had sex education B ( ) Some but less than the majority have had any sex education C ( ) The majority have had sex education IF AT LEAST SOME HAVE HAD SEX EDUCATION (ALTERNATIVE B OR C): Which has been the most common source of the sex education received by your clients before their contact with you? 24. Could your clients. at least in principle. have turned anywhere else than to you for obtaining the kind of sex education offered by you? ) We do not ofTer any sex education ) No ( ) Yes. Where could they have turned? _____________ _ IF YES: What made the clients. in your opinion. turn to you? 149 25. Does the programme/project offer contraceptive services to young people? ) No ) Yes IF YES: Could your clients, at least in principle, have turned elsewhere for contraceptive services? ) No ) Yes IF YES: What made the clients. in your op1nion. turn to you'l 26. What methods have been used in order to make the programme/project known to potential users? 27. Which ways of communicating the existence of the programme/project and its services have been the most important? 28. Have you when trying to communica1e your existence to the potential users encountered any particular obstacles? No. there have been no problems making the programme;project known to potential users. PASS TO QUESTION 31 Yes, there have been problems for us in making the programme/project known to potential users IF OBSTACLES TO MAKING PROGRAMME KNOWN (QUESTION 28 ANSWERED WITH YES): 29. Which obstacles have been encountered when trying to make the program- me project known? YOU MAY CHECK MORE THAN ONE ALTERNATIVE Lack of money Lack of access to target group Lack of cooperation from other organi- zation , institution. Please specify Legal problems. Please specify _ __ _ Other. Please specify ________ _ 30. How have these obstacles affected the programme project? ALL: 150 31. There re ma ny poss ibl e obstacles to the success of a progra mme projec t for fa mil y iJlanning a nd or sex educa ti on of yo un g peo ple. Some possi bk obstacles are li sted below. We would like yo u to indi ca te fo r eac h of th e obstacles menti oned wh eth er it co uld be sa id to be an obstacle to th e success of yo ur projec t or not. PLEASE GIVE YO U R OPINION BY CH EC KIN G ON TH E SCAL E ON TH E RIGHT OF THE OBSTA C LES MENTION ED. CHEC KING TO THE FAR RIGHT MEANS THAT YO U CONSID ER TH E O BSTAC LES A SEVER E PROBL EM WH EREAS C HEC KING TO TH E FAR LEFT IN TH E SCA LE MEANS THAT TH E OBSTA C LE IS CONSID ERED TO BE NO PROBL EM AT ALL C HEC KIN G AT INT ERM EDIAT E SCA LE ST EPS INDI CAT ES IN TE RM EDIAT E OPI IONS . PL EASE MAK E A CHEC K FOR EACH OBSTA C LE ME TI ONE D. Potenti al client s have too vag ue an idea about famil y pl annin g Potenti a l clie nt s hos til e to fa mil y pl ann ing Potenti a l client s hos ti le to sex education Parent s of potenti a l cli ent s objec t to famil y pl annin g for yo un g people Parent s of potentia l clie nt s object to sex educa ti on for yo ung people General traditi onal values in society Illiteracy The uncooperative a ttitude of boy fri ends That it is not socia ll y recogni 7ed th a t yo un g people have interco urse The geogra phica l loca ti on of the progra mme projec t centre makes it diffic ult to reach Busi ness hours of th e progra mme project may make it difficult fo r potent ia l clie nt s to get in touch Other orga ni za ti ons instituti ons do not tell po ten- tial client s abo ut projec t Constant ri sk of being forced to close due to lac k of money Constant ri sk of being closed down due to lack of politica l suppo rt Lac k of specia list personnel Lack of voluntary wo rk ers Lac k of continued train ing of personnel Problems of coo pera tio n among stafT Lack of clearl y-understood objective Lack of clearly-defi ned target group Lack of equipment I = No problem whatsoever 3 = Some problem 5 = Seve re pro blem 2 3 4 5 Please specify an y o ther import ant obstac le enco untered 151 32 . Were any of these obstacles anticipated when the programme/project started? A ( ) Yes. all obstacles encoun tered were anticipated B ( ) Some obs tacles were anticipated whereas others were not C ( ) No particular obstacle was anticipa ted IF SOME OR NO OBSTACLES WERE ANTICIPATED (QUESTION ANSWERED WITH B OR C): Which of the o bstacles encountered had not been anticipated" 33. Has any ac ti o n been taken to overcome any of the obstacles perceived ? No Yes . Please specify by stating obstacle and describe action taken. Obstacles Action taken --------·- ------ --------------- 34. Which of the following themes are considered to be important in the s1•.rnal education of :·ow1y people accordiny to the point of' rinl' of the proyramme proil'Ct '.' We would dlso like you to indicate whether any of these themes are compulsory in sex education or. on the other hand. considered totally unsuitable for yo un g people accordiny to official ( yoremment ) policy. THE MORE IMPORTANT A THEME IS CONSIDERED. THE FARTHER TO THE RIGHT YOU SHOULD CHECK. THE LESS IMPORTANT A THEME IS CONSIDERED THE FARTHER TO THE LEFT YOU SHOULD CHECK. ALSO. PLEASE INDICATE IF ANY OF THE THEMES ARE COMPULSORY OR CONSIDERED TOTALLY UNSUITABLE FOR EDUCATION OF YOUNG PEOPLE VIEW ACCORDING TO PROGRAMME/PROJECT I = Not important a t all. 3 = Of some importance . GOVERNMENT POLICY 5 = Very important. 2 3 4 5 Not fit for Compulsory young people Sexual ana tomy of humans Sex roles Parenthood Reproductive biology Love Psychology of puberty Religious view of marriage and the family 152 Pornography Intercourse Petting Masturbation Homosexuali ty Contraceptives Venereal diseases Sterilization Abortion Sexual dysfunctions (e.g. impotence) Is there any theme yo u wish to add to this list which is not included. although it is an important theme according to the programme/ project ? 35 . Which of the following groups is it important to reach u-i1h sex educa1ion accord in g to the point of view of the project. and which groups (if any) are included in the present target for the activities of the programme project? ONCE AGAIN PLEASE INDICATE YOUR OPINION BY MAKING A C HECK ON THE SCALE ON THE RIGHT OF THE GROUPS MENTIONED. JUST LIKE BEFORE. THE MORE IMPORTANT IT IS TO GIVE A CE RTAIN GROUP SEX EDUCAT ION . THE FARTHER TO THE RIGHT YOU CHECK . AND THE LESS IMPORTANT IT IS TO GIVE A CERTA IN GROUP SEX EDUCATION . THE FARTHER TO THE LEFT YOU CHECK . IF A GROUP IS INCLUDED IN THE PRESENT TARGET OF THE PROGP.AMME; PROJECT PLEASE CHECK IN THE COLUMN TO THE RIGHT OF THE SCALE Preschool children Children in primary school Children in secondary school Adolescent girls Adolescent boys Girls just below usual age of ma rriage Boys just below usual age of marriage Newly-married women Women with many children Men with many children I = Not important at all as Included in target for sex education target 3 = Of some importance as target for sex education 5 = Very important as target for sex education 2 3 4 5 153 36. Which of the following groups is it important to reac h with family pl a nnin g/counselli ng services according to the point of view of the programme /project. and which groups ( if any) are included in the present target group fo r the ac tivities of the programme/project ? JUST AS BEFORE PLEASE INDI CATE YOUR ANSWER BY MAKING A CHECK ON THE SCALE ON TH E RIGHT OF THE GROUPS MENTION ED. CHECK ING TO THE FAR RIGHT MEANS THAT YOU CONSIDER IT VERY IMPORTANT TO REACH THAT GROUP, WHEREAS CHECKING TO THE FA R LEFT MEANS THAT YOU DO NOT CONSIDER IT IMPORTANT AT ALL TO REAC H THAT GROUP WITH FA MILY PLANNING SERVICES . C HECKING AT INTERM EDIATE SCALE STEPS INDI CATES INTERMEDIATE OPINIONS. IF A GROUP IS INCLU D ED IN THE PRESENT TARGET OF THE PROGRAMM E/PROJ ECT. PLEASE CHEC K IN THE CO LUMN TO THE RI GHT OF THE SCALE. Women with many children Men with many child ren Married women Ma rried men All adult women All adult men Newly-married women Newly-married men Girl s just below usual age of ma rriage Boys just below usua l age of marri age Young girls as soon as possible after menarche Yo un g boys as soo n as possible afte r first emission of semen Not important a t a ll as target for se rvices 3 Of some import ance as ta rget for se rvices 5 Very important as targe t for se rvices 2 3 4 5 Included in present target 37. What position does the government take to the birth rate in the country? ) The birth ra te is too low 154 ) The birth rate is acceptable ) The birth rate is too high ) Do not know 38. What is the availability of various contraceptives for young people? Easily Available available in Available Not Not in shops pharmacies only when available avai lable Condoms Spermicides (foam. jelly) Diaphragms Intra -uterine devices Oral contraceptives Long-acting injectable contraceptives or other public places without prescribed to young at a ll prescription by medical people s taff 39. How many clients received services from the programme project during the last twelve months? Number of boys Number of girls Number of adults 40 . Which services were given to young people? Please give number of young people who received service during the last twelve mo nth s. Sex education Contraceptive se rvice Gynaec o logical medical service other than contraceptive Counse llin g guidance Other . Please specify No . of boys No . of girl s Note th at the total will be greater than the number of clients if any client s have received sen·ices of more than one kind . 41. Of those recci, ing contraceptive service during the la st twelve months. what percentage were advised prescribed each of the following contraceptives') Condoms Spermicides (foam. jelly) Diaphragms Intra-uterine devices Oral contraceptives Lo ng-acting injectable contraceptives Other . Pl ease specify 155 ) No co ntrace pti ves ofTered JOO 0 ., 42. Wh at proport ion of young people leav ing schoo l in your co unt ry have. in yo ur opini on. received fo rm al sex educa ti on 9 43. Wha t proporti on of yo ung people leav in g sc hoo l in yo ur co untry have. in yo ur opini on. easy access to fa mil y planning serv ices9 44 . Wha t pro porti on of yo ung people leav in g school in yo ur co untry have. in your opini on. had int erco urse or a re likely to have interco urse in the nea r future9 45. Wha t proporti on of yo un g people leaving school in the school di strict where the programme/project had most of it s ac tivit ies. have had interco urse o r a re likely to have int erco urse in the nea r future. in your opinion? 46. How old . usua ll y. a re women and men in you r co un try when they ma rry 9 Women a re usua ll y a round Men a re usua ll y around -----yea rs o ld -----yea rs old 47. How o ld . usuall y. a re women me projec t when th ey marry9 Women a re usua ll y aro und Men a re usua ll y around and men in the d is trict of th e progra m- -----yea rs o ld -----yea rs o ld 48. How oft en is the woman pregnant. in the district of the progra mme/project. wh en the coupl e marry \Or sta rt to coha bit under ma rri age- like condit io ns)? In a bout---- 0 ., of th e cases is th e woman pregnant 49. Wh a t proport io n of th e popul ati on remai ns unma rried in the dist ric t of the programme project 9 About----- 0 ,. of the popul ation remains unm arri ed 50. Will you please try to give a brief outl ine o f th e sc hedul e fo r the ac tivit ies within the progra mme project durin g th e wee k preceding thi s9 156 PL EASE INDI CAT E FOR EAC H DAY DU RIN G WHI CH HOU RS VARIO US SERVI CES HAVE BEEN AVAILABL E TO TH E USE RS ' FOR INSTAN CE: Mond ay Gynaecologica l exa minations by prev ious appointment Teenagers Couple counselling. adult s 9 a .m.-1 p.m. 6 a .m.-9 p.m. DAY OF THE WEEK MONDAY : ACTIVITIES HOURS 51 Will yo u please describe how you receive a client who visit s you for th e first time and what service she he is offered as well as what she he is supposed to do 0 52. Is there any fee that you ng people have to pay when consulting the programme project '' ( ) No ( ) Yes IF Y ES: Please indicate the fees for th e various services offe red. Service Fee Is this a n:<luc.:<l fo: for yo ung pco pk on ly0 No Yes WE THANK YOU FOR YOUR KIND COOPERATION AND ASK YOU TO GO THRO UG H THE QUESTIONNAIRE J UST ONCE MORE TO MAKE SURE THAT YOU HAV E ANSWERED ALL QUESTIONS PLEASE DO NOT FORGET TO RETURN THIS QUESTIONNAIRE IMMEDIATELY SINCE IT IS ESSENTIAL THAT THE QUESTIONNAIR E REACHES US BEFORE THE CONSUL TANT VISITS YO U. THIS QUESTIONNAIRE WAS ANSWERED BY ( ) ONE PERSON ; NA MEL y __ _ ( ) A GROUP OF PERSONS WORKING WITH THE PROGRAMME/PROJECT PLEASE FEEL FREE TO ADD ANY COMMENTS YOU FIND APPROPRIATE: 157 V\ 00 Annex 4 SUMMARY OF GOVERNMENT REPLIES TO THE QUESTIONNAIRE Country Albania Algeria Austria Belgium Bulgaria Czechoslovakia Denmark Finland France Legal status of sex education of young people (question I) -0 ~ :.0 ..c: 0 ct ~ ~ 0 z X >, 0 "' :i C. E 0 u X X X X 0 0 ..c: ~ " ct Institutions providing compulsory sex education (question 5) >, ~o E o · - ..c: ~ u 0.."' X c "' -o_ C: 0 O 0 u ..c: " u Vl "' >, E < ~o " 0 ..c: ..c: - u 0 "' C: 2 ~ . ~ C: C: 0 "' -01)- ~ ::, 0 ·= ~ "' "C: ..c: ·- 6 o X Information on family planning (question 10) -;;; 01) ..!/ 0 z " 0 0. - 0 i& "01) - C: - ::, 0 0 z ;>, missing - ~ "'-01) u CJ"' -;E Z 0 X Family planning for young people (question I 2) -;;; 01) ..!/ 0 z "' C: 2 ~ u ·u ·c &;;; Vl ~ X "' - " "'-01) u ""' -; ] Z 0 C: " ~ E :.: co C:" ::, !:: tl..> ~ " 0 Lt E X X missing ------------::---------~ X X missing X X X X X X X X X X Cost of family planning for young people (question 18) -0 CJ N C: :.s " ·-~ E ; _E 0 _, .0 ::::J '-- "' "' ,.; >, " -~~ " - " "' ~ 0 u.. E X X X ~ '-" -- ·u 0 & z"' -;;; "' o-~ g c...:. -c, · - t,/) 11) ~ "' E .= - - ::, "'"'"' 0 0 C: UE8 German Democratic Republic Federal Republic of Germany X X X X X X X Greece X - X X X Hungary X X X X X X X X X X Iceland X X X X X X X --- Ireland Italy Luxembourg X X X X X X X X Malta Monaco X X X missing missing Morocco Netherlands Norway X X X X X X X X Poland - --- Portugal Romania San Marino Spain X X X X Sweden Switzerland X X X X X X X X --- Turkey USSR United Kingdom X X X X Yugoslavia X X X X X X X X X X X VI '-0 °' 0 Countrv Albania Algeria Austria Belgium Bulg;,ria Czechoslova kia Denmark Finland France German Democratic Republic Federal Republic -_, C: 0 National famil y planning for yo ung peo ple (que,11on I 9) ;; ..c := ~ ~i=~ ~ ~ -C !.I C.. ~ > /'; ..C: 0 0 f- Ol;..C: X X X X co C: , ~ .:::. · C 0 ! .Ei~ X ~ CJ ..c: 6 Local muni- cipal family planning for yo ung people (question 20) ._, C: ::, z X X F. > X X X - - -- Economic support to non- government sex education (question 21) ._, ~ z ,. > X X X X X Economic support to no n- go vernment famil y planning (question 22) ._, C: z X X F ._, >- X X X ~ ..:: X X Government a11i1ude to birth-rate (question 27) ._, :c: c'.. ._, ._, < X missing ..c: ,,, ..c: ..:: X Pro portion of yo ung people receiving sex education (question 28) missing 100 100 90 missing Proportion of yo ung people with easy access to family planning (question 29) missing 100 100 100 missing o f German y x x x x x missing missi ng Greece X X X X X missing missing Hungary X X missing X X missing 100 100 Iceland X X X X missing 100 100 Ireland Italy Luxembourg X X X X X missing missing Malta Monaco missing missing missing missing X 25 missing Morocco Netherlands Norway X X X X X X 100 missing Poland --- Portugal Romania San Marino Spain X X X X missing 5 15 Sweden Switzerland X X X X X X 50 50 Turkey USSR United Kingdom X X X X missing (75) 100 Yugoslavia X X X X X X missing 100 100 0-, Annex 5 DEMOGRAPHIC DATA ON COUNTRIES WHERE SPECIAL PROGRAMMES/ PROJECTS WERE STUDIED Belgium Total population ( 1980): 9 920 000 Children 0- 14 years: 20.3 % Urban population: 72.4 % Adolescents 15- 19 years: 8.2 ° 0 Projected total population, year 2000: IO 762 000 Children 0- 14 years: 20.54 % Adolescents 15- 19 years: 6.5 o/,, Urban population: 78 .9 % Number of live births by mothers 19 years old or less (1977): 9672 Above as percentage of all births where age of mother known: 7.9 % Number of legally induced abortions in women 15- 19 years old or less: none legally induced Above as percentage of a ll legally induced abortions where age of woman known: none legally induced Legal age of marriage ( 1977) Groom: 18 Bride: 15 Sources: Demographic year book . United Nations, I 979. Selected demographic indicators by country. / 950- 2000. United Nations (ST / ESA/SER R/38) . Government reply to Digest of health statistics . World population prospects as assessed in 1980. United Nations (ST /ESA /SER.A/78) . Federal Republic of Germany Total Population (I 980): 61 561 000 Children 0- 14 years : I 8.5 % Urban population: 84.7 % Adolescents 15- 19 years: 8.2 % Projected total population, year 2000: 59 546 000 Children 0- 14 years: 18.60 % Adolescents 15- 19 years: 5.2 % Urban population : 89 .3 % Number of live births by mothers 19 years old or less (1978): 39 786 162 Above as percentage of all births where age of mother known: 6.9 % Number of legally induced abortions in women 15- 19 years old or less ( 1978): 9409 Above as percentage of all legally induced abortions where age of woman known: 13.0 % Legal age of marriage ( 1982) Groom: 18 Bride: 18 Sources: Dmwgraphic year book . United Nations. 1979 Se/ened demographic indicators by country. / 950- 2000. United Na tions (ST / ESA/SER R/38\. Gort . Reply to Diyes t of Health Statistics. World population prospects as assessed in 1980. United Nations (ST / ESA/SER .A/78). Italy Total population ( 1981) 57200 000 Children 0- 14 years: 21.8 ° 0 Adolescents 15- 19 years: 7.9 o/0 Urban population 69 .3 ° 0 Projected total population . year 2000: 59 I 08 000 Chi ldren 0- 14 years : 19 .58 ° 11 Adolescents 15- 19 years: 6. 1 % Urban population : 78 .1 ° 0 Number of births by mothers I 9 years old or less ( I 967): 85 785 Above as percentage of all births where age of mother known: 9.1 o/0 Number of legally induced abortions in women 15- 19 years old or less: no data Above as percentage of all legally induced abortions where age of woman known: no data Legal age of marriage ( 1977) Groom: 16 Bride: 15 Sources: Demographic year book . United Nations. 1979. Selected demograph ic indicators hy country . /950- 2000. United Na tio ns (ST, ESA , SER . R 38). Noti:iario statistico. Centrale di Statistica . World populat ion prospects as assessed in / 980 . United Nation s (ST ESA SER .A, 78) . World health statistics annual. Morocco Total population ( 1981 ): 21 800 000 Children 0- 14 years: 46.0 ° 0 Adolescents 15- 19 years: 11.4 ° 11 Urban population: 40.6 ° 0 ( 1978) 163 Projected total population. year 2000: 36 149 000 Children 0- 14 years: 39.59 ° 0 Adolescents 15- 19 years: I I. 3 ° 0 Urban population: 54.9 o/., Number of births by mothers 19 years old or less: no data Above as percentage of all births where age of mother known : no data Number of legally induced abortions in women 15 - 19 years old or less: very restricted legality Above as percentage of all legally induced abortions where age of woman known: no data Legal age of marriage ( 1971) Groom : 18 Bride: 15 Sources: Demographic year hook . United Nations. 1979. Selected demographic indirn tors hy countrr. /950 - 2000. United Nations (ST/ ESA/SER . R/ 38) . World Bank {///as 1981. provisional data . World population prospects as as.1·e.1·.H'd in /980. United Nations (ST / ESA/SE R. A/78) Netherlands Total population: (1980) 14 790 000 Children 0- 14 years: 22.6 o/., Adolescents 15- 19 years: 8.85 o/., Urhan population 76.3 o/., Projected total population , year 2000: 15 487 000 Children 0- 14 years: 20.3 o/., Adolescents 15- 19 years: 6.00° 0 Urban population: 79.9 o/., Number of births by mothers 19 years old or less (1978): 5637 Above as percentage of all births where age of mother known : 3.2 '%, Number of legally induced abortions in women aged 15- I 9 years or less: no data Above as percentage of all legally induced abortions where age of woman known: no data Legal age of marriage ( 1978) Groom: 18 Bride: 16 Sources: Demographic year book . United Nations, 1979. 164 Selected demographic indicators by country. 1950- 2000. United Nations (ST / ESA/SER R/ 38). World population and its age-sex composition by country. 1950- 2000: demographic es timation and projection as assessed in 1978. United Nations (ESA /P/WP.65). Poland Total population (1981) : 36000000 Children 0 - 14 years: 24.0° 0 Adolescents 15- 19 years: 7.8° 0 Urban population : 57.7 °,0 (1978) Projected total population. year 2000: 41 2 I 7 Chi ldren 0 - 14 years: 21.4° 0 Adolescents 15 - 19 years: 8.1°., Urban population : 67.7 °., Number of births by mothers 19 years old or less ( 1978): 49460 Above as percentage of all births where age of mother known: 7.4 °., Number of legally induced abortions where woman is 15 - 19 years old or less: no data Above as percentage of all legall y induced abortions where age of woman is known: no data Legal age of marriage ( 1978): Groom : 21 Bride: 18 Sources: Demographic rear hook. United Natio ns. 19 79. Selected demographic indirntors hr co1111t1T. 1950 2()00. Uni ted Nations (ST ESA SER .R 38) W orld Bank atlas 1981. provisional data . World pop11/ation prospl'C'ts as a.1·s1'ssed in 1\11/() _ United Nations (ST/ ESA1SER.A 178). Portugal Total population ( 1980): 9 856 000 Children 0 - 14 years: 26.40° 0 Adolescents 15 - 19 years: 9.2 ° 0 Urban population : 30.6 ° 0 Projected total population, year 2000: 11 154 000 Children 0 - 14 years: 22.9 % Adolescents 15- 19 years: 7.8 ° 0 Urban population: 44.4 °,0 Number of births by mothers 19 yea rs old or less ( I 975): 15 558 Above as percentage of all births where age of mother known: 8. 7 ° 0 Number of legally induced abortions where woman is 15- 19 years old or less: not lega l Above as percentage of all legally induced abortions where age of woman known: no data Legal age of marriage ( 1978): Groom: 16 Bride: 14 165 Sources: Demographic year book . United Nations. 1979. Selec ted demographic indicators hy country, 1950- 2000. United Nations (ST/ESA/SER .R/38) World population prospects as asses.l'ed in 1980. United Nations (ST/ESA/SER .A/78). Sweden Total popula tion ( 1980): 8318000 Children 0- 14 years: 19.6 o/0 Adolescents 15- 19 years: 7.0 o/., Urban population: 86.7 % ( I 975) Projected tota l population, year 2000: 8 088 000 Chi ld ren 0 - 14 years: 19.3 % Adolescents 15- I 9 yea rs: 3.5 o/., U rban population: 92.3 o/., Number of births by mothers 19 years o ld or less ( 1978): 5035 Above as percentage of all births where age of mother known : 5.4 ° 0 Number of legally induced abortions where woman is 15- 19 years old or less ( 1978): 6265 Above as percentage of a ll legally induced abort ion s where age of woman known: 19.6 ° 0 Legal age of marriage ( 1978): Groom: 18 Bride: 18 Sources: Demographic )'(' l:Jr hook . United Nations. I 979. Selected demographic indirntor.l' hr co1111trr. 1950 - 2000. U nited Nations (ST, ESA ,SER R 38) Government reply to Digest of health statistics . World population prospects as assessed in 1980. Uni ted Nations (ST, ESA SE R.A 78) Yugoslavia Total popul ation ( 198 I): 22 354 000 Children 0- 14 years: 24.4° 0 Adolescents 15- 19 years: 8.3° 0 Urban population: 38 .6 °., Projected total population. yea r 2000: 25 168 000 Children 0 - 14 years: 21.0° 0 Adolescents 15- 19 years: 7.1° 0 Urban population: 57.5 °0 Number of births by moth ers I 9 yea rs o ld or less ( 1977): 46 263 Above as percentage of a ll births where age of mother known : 12. 1 ° 0 Number of legally induced abo rtions where woman is 15- 19 years old or less ( 1968): 12 897 166 Above as percentage of a ll lega ll y induced abo rti ons where age of woman is kno wn : 5.3 '/0 Lega l age o f G room : Brid e: ma rri age ( 1977): 18 18 Sources: Demographic rear hook . United Na tions. I 979 . Seln red demographic indirn ror., hr cou111rr . IY50 2li/JO . Un ited Na t io ns (ST/ESA;SE R. R;38) . Govern ment reply to Digesr of ill'alrh s1a1i.H1cs. World popu/a rion pro.1p,•C1.1· as 1Jss, ·ssed i11 I Y!W . United Na ti on s (ST/ESA /SE R.A '78) 167 Annex 6 LIST OF PEOPLE MET AND INSTITUTIONS VISITED Belgium Aime r Je uncs. Brusse ls Pl a nnin g Josa ph a t. Bru sse ls K a th o li cke U ni ve rsit c it. Leuvcn Fed era ti on be ige po ur le Plannin g fa milial ct !' Educa ti o n scx uell c Federal Republic of Germany Pro Famili a Bundesvc rba nd Pro Famili a Bera tun gss tcll e. Bo rnhe im . F ra nkfu rt Italy Mini stry of Hea lth Centro lntcrn az io nal c d eg li Studi dclla Fami gli a. Milan U ni o ne lt a li a na dei Ce ntri dcll a Educaz io nc Ma t rim oni a lc c Prema trim o ni a le Milan Mrs Cornett c-T oui ssa nt a nd co ll a bo ra to rs D r F ra nce D o nn ay an J co ll a bo ra to rs Professo r Wilfri cd Dumo n Mrs Ray mo nde Mcrcenier and co ll a bora to rs Mr Joachim vo n Baross Mr Rei nho ld G runbe rg M s Erika Schm idt Beh re ns Dr Ca rl o Vetere Reve rend Fa the r C ha rl es Vell a Dr Ro berto Ma uri M s Ant o niett a Co rradini Osped a lc F a te Bene Fra telli . Ro me Pro fesso r Ro ma no F o rlco Ce nt ro di Med ici na Socia le. G iuglian o. Na ples Morocco Ministry o f Hea lth . Populati o n Divi sion Mini s try of Yo uth a nd Spo rt Ministry of Educa tio n Centre de Refe rence. Ra ba t M o bile M CH uni t. Kh cm isset L'Assoc ia t ion marocai ne de Pl a nifi ca t io n famili a lc 168 Dr Stefa nia Ma ri a ni Dr Lucia no Ca rrin o a nd col la bo rato rs Dr Jo uahri Mrs Rac hdi Mr Yassinc Mr Joha red Sa id C ha rgui a nd col la bora to rs Dr Radi M ohamed Netherlands Ministry of Health Rutgers Stichting Rutgershuis, The Hague The Mello Project Poland Family Health Department , National Maternal and Child Health Research Institute, Warsaw Institute of Psychology and Education , University of Warsaw Towarzystwo Rozwoju Rodziny (TRR) TRR Warsaw Clinic Portugal Ministry for Social Affairs Directorate-Generai of Health Director of Health Centres, Lisbon Area National School of Health Dr Frits Wafelbakker Mr Willem de Regt Dr H. I. A. T. Doppenberg Dr Gert Sanders and collaborator Dr Aldona Sito Professor Andrzej Jaczewski and collaborator Professor Mikolaj Kozakiewicz Dr Krystyna Jakowicka Secretary of State for Family Affairs Teresa Macedo Secretary of State for Health - Paulo Mendo Dr Maria Tome-Almeida Dr Joaquim Rosa Paixao Dr Maria Gomes do Prado Quintino Dr Geraldo Dr Fernanda Navarro and collaborators Health centre of the district of Lisbon (under the Directora te-General of Health) Sofia Albecasses health centre in Lisbon (under the Directorate-General of Health) Domingos Barreiros health centre (under Santa Casa de Misericordia de Lisboa) Hospital Santo Antonio, Oporto APF Lisbon APF Oporto Sweden Dr Albino Aroso Mrs Eugenia Moura Dr Miguel Oliviera de Silva Dr Albino Aroso Dr Antonio Palha Dr Jose Cixeira de Sousa Youth Advisory Clinic, Stockholm School Board 169 Yugoslavia Fa mil y Pl a nning Council. Autonomous Provi nce of Vojvodina Uni ve rsity Hospi ta l. Novi Sad, Vojvodina Teachers College, Nik sic , Mo ntenegro Nik sic Hospita l. Montenegro University Hospi ta l. Ljublja na. Slovenia 170 Dr Kri va k Ms Veskovic Professo r Berisla v Beric Dr Nila K apo r-Sta nul ovic Professor Rade Delibasic Ms Djuka nov ic Dr Cizmovic Professo r Lidija Andol sek Dr Majda Kustrin-Marolt Ms Hanja Kuhelj Ms Maca M acek H O p u b l i c a t i o n s m a y b e o b t a i n e d , d i r e c t o r t h r o u g h b o o k s e l l e r s , f r o m : E R I A : S o c 1 i : 1 i : N a t i o n a l e d " E d 1 1 i o n e t d e D i f f u . s i o n , 3 b d Z i r o u l L U X E M B O U R G : L i b r a i r i e d u C e n t r e , 4 9 b d R o y a l , L t . : x E M I I O U t G Y o u c e f . A L G I E R S M A L A W I : M a l a w i B o o k S e r v i c e , P . O . B o • 3 0 0 4 4 , C h i c h i t i , B u , ; T V R E 3 R G E N T I ! I I A : C a r l o s H i r s c h S R L . F l o r i d a 1 6 5 , G a l e r i a s G u e m e s , M A L A Y S I A : T h e W H O P r o g r a m m e C o o r d i n a t o r , R o o m 1 0 0 4 , 1 0 t h E s c r i t o r i o 4 5 3 / 4 6 5 , B u , - ; o s A I R E S F l o o r . W i s m a L i m F o o Y o n g ( f o r m e r l y F i t z p a t r i c k ' s B u i l d i n g ) , J a l a n U S T R A U A : H u n t e r P u b l i c a t i o n s . 5 8 A G i p p s S t r e e t . C o w N G W O O O , R a j a C h u l a n , K t . : A l A L t . : M l ' t . : K 0 S - 1 0 ; P . O . B o • 2 5 5 0 , K L A l A L t . : M l ' t . : K V I C 3 0 6 6 - A u . s t r a l i a n G o v e r n m e n t P u b l i s h i n g S e r v i c e ! M a i l o r d t r 0 1 - - 0 2 - P a r r y ' s B o o k C e n t e r , K . L . H i l t o n H o t e l , J i n . T r e a c h e r , P . O . s a / t f 4 P O B o • 8 4 , C A , I I E H A A . C T 2 6 0 0 : o r o • · t r r h t c o u n t r r f r o m B o • 9 6 0 , K U A l A l t . : M l ' t . : K A u s t r a l i a n G o v e r n m e n t P u b l i s h i n g S e r v i c e B o o k s h o p s a t : 1 0 A l i n p M A W I V E S : S H I n d i a , W H O R e g i o n a l o m c e S t r e e t , C A ' < B E R R A C r r v A C . T 2 6 0 0 : 2 ~ A d e l a i d e S t r e e t , B a t S a A N E . M E X I C O : L i b r e r i a I n t e r n a c i o n a l , S . A . d e C . V . , A v . S o n o r a 2 0 6 , 0 6 1 0 0 . Q u e e n s l a n d 4 0 0 0 : 3 4 7 S w a n S l o n S t r e e t , M E l . l l U L R " E . V I C 3 0 0 0 ; 3 0 9 M t x i c o , D . F . P i l l S t r e e t . S V D M Y . N S . W . 2 0 0 0 ; M t N e w m a n H o u s e , 2 0 0 S t . M O N G O L I A : s u I n d i a , W H O R e g i o n a l O f f i c e G e o r g e ' s T e r r a c e , P E R T H , W A 6 0 0 0 : I n d u s t r y H o u . s e , 1 2 P i r i e S t r e e t , M O R O C C O : E d i t i o n s L a P o n e . 2 8 1 a v e n u e M o h a m m e d V , R A I I A T A D n A I D E . S A 5 0 0 0 ; 1 5 6 - 1 6 2 M a c q u a r i e S l r e e t H D I I A R T , T A S 7 0 0 0 - M O Z A M B I Q U E : I N L D , C a i • a P o s t a l 4 0 3 0 , M A P \ . ' T O R . H i l l & S o n L t d , 6 0 8 S t . K i l d a R o a d , M E U I O t . : R N E . V I C 3 0 0 4 ; N E P A L : S H I n d i a , W H O R e g i o n a l O f f i c e L a w s o n H o u . s e . 1 0 - 1 2 C l a r k S t r e e t , C ' R o w · s . E S T , N S W 2 0 6 5 E T H E R L A N D S : M e d i c a l B o o k s E u r o p e B V , N o o r d e r w a l 3 8 , ' 2 4 1 B L l i S T R I A : G e r o l d & C o . , G r a b e n 3 1 , 1 0 1 I V 1 E " ' A I l o c H E M A N G I . A D F . S H : T h e W H O P r o g r a m m e C o o r d i n a t o r . G . P . O . B o • 2 5 0 , N E W Z E A L A N D : G o v e r n m e n t P r i n t i n g O f f i c e , P u b l i c a t i o n s S e c t i o n , D H A K A S - T h e A s s o c i a t i o n o f V o l u n t a r y A g e n c i e s . P . O . B o • 5 0 4 5 , M u l g r a v e S t r e e t , P r i v a t e B a g , W E W . > ; < ; J O , ; I ; W a l t e r S t r e e t , W E L · D H A K A S U N G T O N : W o r l d T r a d e B u i l d i n g , C u b a c a d e , C u b a S t r e e t , W E U I N G T O , . . E L G l t : M : F o r l > o o A s O f f i c e I n t e r n a t i o n a l d e L i b r a i r i e s . a . . a v e n u e G o u r n m t n t B o o A s h o p s a t . H a n n a f o r d B u n o n B u i l d i n g , R u t l a n d M a r n i • 3 0 . 1 0 5 0 B K L ~ E U . F o r ~ r i o d i c a / . r a n d s u b s c r i p u o n s : O f f i c e S t r e e t , P n v a t e B a g , A t , ; c K L A " D ; 1 5 9 H e r e f o r d S t r e e t , P r i v a t e B a g , l n t e r n a u o n a l d e s P i : r i o d i q u e s , a , e n u e M a r n i • 3 0 . 1 0 5 0 B R L ' S S E L S - C H R I S T l H L ' R C H ; A l e x a n d r a S t r e e t , P . O . B o • 8 5 7 , H A M I L T O ' - ; T & G S u b s m p 1 1 o n s t o W o r l d l f , a l , h o n / _ , J e a n d e L a n n o y , 2 0 2 a v e n u e d u B u i l d i n g . P r i n c e s S t r e e t . P 0 . B o • 1 1 0 4 , D t . : N E O I N - R . H i l l & S o n , R m , 1 0 6 0 B R L ~ £ U L t d . I d e a l H o u . s e , C n r G i l l i e s A v e n u e & E d e n S t . . N e w m a r k e t . A O C K • H I . f f A N : s t t I n d i a . W H O R e g i o n a l O f f i c e u , - ; o I W A N A : 8 o t s a l o B o o k s ( P i y ) L t d . . P 0 . B o . 1 5 3 2 . G A - 0 ' - E I G E R I A : U n i , e r s i t y B o o k s h o p N i g e r i a L t d . U n i v e r s i t y o f l h a d a n . R A Z I I . : B 1 b h 0 1 e c a R e g i o n a l d e M e d 1 a n a O M S / O P S . U n i d a d e d e J I I A D A " V e n d a d e P u b h c a , l l e s , C a . . a P o S l a l 2 0 . 3 8 I . V i l a C l e m e n t i n o , 0 4 0 2 3 N O R W A y : J . G . T a n u m A / S , P . O . B o • I J 7 7 S e n t r u m . O s w I S M J P A L L < > , S . P P A K I S T A N : M i r z a B o o k A g e ~ . 6 5 S h a h r a h - ~ i d - E - A u m . P . O . L ' R M A : < t t I n d i a , W H O R e g i o n a l O f f i c e B o • 7 2 9 , L A H O R E 3 ; S a s t L i m 1 1 e d . S a s i C e n t r e , G . P . O . B o x 7 7 9 , I . I . A N A D A : C a n a d i a n P u b l i c H e a l t h A s s o c i a t i o n . 1 3 3 5 C a r l i n g A v e n u e , C h u n d r i p r R o a d , K A R A C H I S u i t e 2 1 0 . O T T A W A , O n t . K I Z 8 N 8 . S u b s c r i p t i o n o r d t r s , a u o m p a n i t d P A P U A N E W G U I N E A : T h e W H O P r o g r a m m e C o o r d i n a t o r . P . O . b . - , · h t q u t m a d , o u t 1 0 t h t R o y a l B a n k o f C a n a d a , O T T A W A , A c c o u n t B o , 6 4 6 . K o , . E O O I I L W o r l d H e a l t h O r g a n i z a t i o n , m a y a l s o I > , s t n t t o t h e W o r l d H e a l t h P H I U P P I N F . S : W o r l d H e a l t h O r p n i z a t i o n , R e g i o n a l O f f i c e f o r 1 h e O r g a n i z a t i o n . P O B o , 1 8 0 0 , P o s t a l S t a 1 1 o n B . O T T A W A , O n t . K I P S R S . W e s t e r n P a c i f i c , P . O B o x 2 9 3 2 , M A M l A - T h e M o d e r n B o o k C o m • H I N A : C h i n a N a t i o n a l P u b l i c a u o n s l m p o n & h p o n C o r p o r a t i o n , p a n y I n c . . P . O . B o • 6 3 2 . 9 2 2 R i z a l A v e n u e . M A , . l l A 2 8 0 0 P O . B o • 8 8 . 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S E O L L S o g a d e 3 5 . 1 3 1 0 O l l ' l " H A G E " K ( T e l • + 4 5 I 1 2 8 5 7 0 ) S I E R R A L E O N E : N j a l a l ! n i v e r s i t y C o l l e g e B o o k s h o p t L : n i , · c r s i t ) o f C t : A D O R : L 1 b r e n a C i e n t i f i c a S A , P O B o • 3 6 2 , L u q u e l l 3 . S i e r r a L e o n e l , P r i , 7 1 1 e M a i l B a g , F R E E T O " - " G L A V A Q U I I Q G Y P T : O s , n s O l f i c e f o r B o o k s , n d R e > i e . , , . 5 0 K a s r 1 - . 1 N i l S l r e e t , C A I R " S I N G A P O R E : T h e W H P r o g r a m m e C o o r d i n a t o r , 1 4 4 M o u l m e i n R o a d , S I N G A P O R f I I 3 0 ; N e w t o n P 0 . B o x 3 I . S t ' - G A P O R E 9 1 2 2 - U J : T h • W H O P r o g r a m m e C o o r d m a 1 o r . p 0 . B o • 1 1 3 . S L V A S e l e c t B o o k s ( P i e ) L t d . 2 1 5 T a n g h n S h o p p i n g C e n t r e , 2 / f . 1 9 T a n g l i n ~ U N D : A k a t e e m i n e n K i r J a k a u p p a . K e s k u s k a t u 2 , 0 0 1 0 1 H u . s 1 " " ' ' R o a d . s i , G A P O I I E J O N C E : L 1 b r a 1 n e A r n e u e , 2 r u e C a s 1 m 1 r - D e l a v i g n e . 7 5 0 0 6 P A R I S S O L ' T H A F R I C A : V a n S c h a i k ' s B o o k S l o r e ( l ' t ) I L t d . P . O . B o x ~ 2 4 . 2 6 8 A B O N : l . 1 b r a m e l ! n i v e m t a i r e d u G a b o n . B . P . 3 8 8 1 . L I B R E V I I H C h u r c h s t r e e l , P R E T O R I A O O O I E K M A N D E M < X . R A T I C R E P U B L I C : B u c h h a u s L e i p l l g , P o s t f a c h S P A I N : C o m e r c i a l A t h e n e u m S . A . , C o n s e j o d e C i e n t o 1 3 0 - 1 3 6 , B A R C f · J 4 0 . 7 0 I L U P l J G L O " A I S ; G e n e r a l M o s c a r d o 2 9 . M A D R I i > 2 0 - L i b r e r i a D i a z d e E R M A N Y , F E D E R A L R E P U B I . I C O F : G o \ 1 - V e r l a g G m b H . G i n n • S a n t o s , L a g a s c a 9 5 y M a l d o n a d o 6 , M A l > R l l l 6 ; B a l m e s 4 1 7 y 4 1 9 , h e 1 m e r s t , . . . . , 2 0 . P o s t f a c h 5 3 6 0 , 6 2 3 6 E s c H _ , - W . E . S a a r b a c h , B A R C E U > " A 2 2 p f h 1 0 0 2 5 0 0 0 K I S I - S R I U ! ' \ K A : s t t I n d i a . W H O R e g i o n a l O f f i c e O S I a c 1 6 I • f o l l e r s t r a s s e • O " I - A e x . H o r n . · p i e g e S W E D E N : F o r b o o h · A k t i e b o l a " " t C . E . F r i l l e > K u n g l . H o v b o k h a n d e l . g a s s e 9 . P o s t f a c h 3 3 4 0 , 6 2 0 0 W 1 E S B A D £ " e • H A N A : h d e s E n t e r p r i s e s . P . O . B o • 1 6 2 8 . A C C R A R e g e n n g s g a t a n 1 2 , 1 0 3 2 7 S T O n < H O L M F o r p , n o d i < - a l . < . W e n n c r g r e n • R E E C E : G ( ' E l e f t h e r o u d a k i s S . A . L i b r a i r i e m 1 e r n a t 1 o n a l e . r u e W i l l i a m s A B . B o x 3 0 0 0 4 . 1 0 4 2 5 S T O C K H o u , ' - i k 1 > 4 . A I H E " s r r 1 2 6 ) S W i T . l E R I . A N D : M e d , z i n i s c h e r V e r l a g H a n , H u b e r . U i n g g a s s t r a s s e A m : M a • B o u c h e r e a u . L t b r a m e - A l a C a r a v e l l e " , B o i t e p ( ) S l a l e 1 1 I • - 0 : ! i ~ ~ ~ ~ i ; , : ~ n d i a . W H O R - i o n a l O f f i c e B , P O R T · A l • l ' R l ' < l • e O N G K O N G : H o n g K o n g G o , · e r n m e n t I n f o r m a t i o n S e r v i c e s . 9 e a . T I : N I S I A : S o c i i : t c T u m s i e n n e d e D i f f u s i o n , 5 a , · e n u e d e C a n h a g e , T L , I S c o n s f , e l d H o u , e , t , c h F l o o r . Q u e e n · , R o a d . C e n t r a l , V I C T O R I A n : R K E Y : H a s e t K 1 t a p e v i , 4 6 9 l s t i k l a l C a d d e s i . B e y o g l u . I S T A ' < l l l L : ! I I G A R l : K u l t u r a . P . O . B . 1 4 9 . B L D A P E S T 6 2 - A k a d c m i a , K o n p e s - l i N I T E D K I N G D O M : H . M . S t a t i o n e r y O f f i c e : 4 9 H i g h H o l b o r n , b o l t . V a c , u t c a 2 2 . B l D A P E S T V U I M X > , W C I V 6 H B : I l a C a S l l e S t r e e t . E D l " I L R G H E H 2 3 A R : B O E U : - . D : S n a c b J o r n J o n . . o n & C o . . P O B o • I I l l . H a f n a r s t r a e u 9 , C h i c h e S 1 e r S t r e e t . B l U A S T B T I 4 J Y ; B r a z e n n o s e S t r e e t . M A , . C H E S T E R R £ n J A \ I • M 6 0 S A S : 2 5 8 B r o a d S t r e e t , B I K M l " G H A M B l 2 H E : S o u t h e ) H o u s e . : - . D I A : W H O R e g i o n a l O f f i c e f o r S o u t h - E . a s t A " a . W o r l d H e a l t h W i n e S t r e e t , B R I S T O L B S I 2 8 Q . A l l m a , / o r d t r s s h o u l d I > , s , • n , 1 0 - H o u s e , l n d r a p r a 1 h a E S l a t e , M a h a t m a G a n d h i R o a d , J \ , f " ' D n H I H M S O P u b l i c a t i o n s C e n t r e . S I N i n e E l m s L a n e , L o " o " " S W 8 S D R 1 1 0 0 0 2 - ( h f o r d B o o k & S t a t i o n e r y C o . . S c i n d i a H o u s e , N E w D f L H I U N I T E D S T A T E S O F A M E R I C A : S m 1 1 l , a n d h u l k , o p i t s o f m d i • I 1 0 0 0 1 . J 7 P a r k S t r e e t . C A L C L T T A 7 0 0 0 1 6 ( S t 1 / , , a g , n t ) , · , d u a l p u b l i c a t i o n s 1 n o t s u b s c r i p t i o n s / . W H O P u b l i c a t i o n s C e n t r e . · o o N E S I A : p T . K a l m a n M e d i a P u s a k a . P u s a t P e r d a g a n g a n S e n e n . L S A . 4 9 S h e r i d a n A v e n u e . A L 8 A S Y , N Y 1 2 2 1 0 . S u b J < · r i p t i o 1 1 1 S u i > - B l o c k 1 , 4 t h H o o r . p O . B o , 3 4 3 3 / J k t . ! . K A R I A . , c n p 1 w 1 1 o r d t r s , a c . - o m p a m t d h _ , c h t < · k m u d , o u t t o t h t C h e m i c a l R A ! l i ( I S U M I C R E P L : B U C O F ) : I r a n U n i v e r s n y P r e s s . 8 5 P a r k B a n k . ' - e w Y o r k , A c r o u n t W o r l d H e a l t h O r g a n i z a t i o n , s h o u l d t , , , s , n t A , e n u e . P 0 . B o , 5 4 / S S J . T E H R A ' t o t h t W o r l d H e a l t h O r g a n i z a t i o n . P O B o • 5 2 8 4 . C h u r c h S t r e e t S i a • R A Q : M 1 m m y o f I n f o r m a t i o n , i - . a t i o n a l H o u s e f o r P u b l i s h i n g . D i s t r ~ l i o n . N r w Y < > R K , N Y ! 0 2 4 9 . C o m , . , p o n d m c e < ' 1 > n c t r n i n 1 1 s u h s c n p 1 1 0 n s b u t i n g a n d A d , e n , s i n g . B A G H D A D , h o u l d h e a d d r r = d t o t h , W o r l d H e a l t h O r g a n i z a t i o n . D i S 1 r i h u 1 i o n R E U N D : T D C P u h l i s h e r s , 1 2 N o n h h e d e n c k S t r e e t . D L B I J ' , I a n d S a l e s . 1 2 1 1 G r , ; E \ A 2 7 . S w i t z e r l a n d . P u b l i , · a u o n . , a r , a / . r o a , a , 1 - ( T e l 7 4 4 8 3 5 - 7 4 9 6 7 7 ) a h l t f r o m t h t U n i t e d N a t i o n s B o o k s h o p , N E W Y O R K . N Y 1 0 0 1 7 / r , t a i / R A E L : H e i l i g e r & C o . . l i - . a t h a n S t r a u s s S t r e e t , J I R L S A t E M ~ 2 2 7 o n / , I A L \ ' : E d , z 1 o m M i n e n a M e d i c a , C o r s o B r a m a n t e 8 3 - 8 5 , 1 0 1 2 6 t : R U G t : A \ ' : L i b r e r i a A g r o p e c u a r i a S . R L . , C a s i l l a d e C o r r e o 1 7 5 5 , T L R I ' < ; V i a L a m a r m o r a 3 , 2 0 1 0 0 M i u . , A l z a i b a r l n 8 , M O " T F \ ' I O E O A P A N : M a r u z e n C o . L i d . P O B o • 5 0 5 0 . T { ) l ( \ O J n 1 e r n a 1 1 o n a l . 1 0 0 - 3 1 t : S S R : F o r r , a d t r s m t h t 1 . , S S R r , q u 1 r i n l ( R u s s l a 1 1 t d m o n s . K o r n ' ° ' O R D A N , l l t E H A S H U I I T E K I N G D O M o t · : f o r d a n B o o k C e n t r e m o l s k i J p r o s p e k t 1 8 . M e d i c i n s k a j a K n 1 g a . M o s c o w - F o r r , a d m C o : L i d . . l n l \ e r s n r S t r e e t , P O . l k " 3 0 1 • A I - J u b e 1 h a ) . A \ I M A ' 0 1 1 1 , i d e t h t l S S R r , q u i r i n l ( R u s s i a n , d u w m . K u z n e c k i j m o S I 1 8 , l . . \ \ A I T : T h e K u , . a u B o o k s h o p s C o . L i d . T h u n a y a n A J . G h a n e m B l d g , M e ! d u n a r o d n a j a K n i p , M o s c o w G - 2 0 0 P . O . B o , 2 ~ 2 . K l W A I T V E N E Z U E U : L i b r e r i a d e l E s t e . A p a n a d o 6 0 . 3 3 7 . C A R A C A S 1 0 6 - L 1 - O P t : O P I . E ' S o t : ! \ ' I O C R A T I C R t : P t : B I . I C : T h e W H O P r o g r a m m e b r e r i a M t d i c a P a r i s , A p a n a d o 6 0 . 6 8 1 . C A R A < · A s 1 0 6 ' C o o r d i n a t o r . P O B o , 3 4 3 . V 1 E ' T I A ' E V U G O S U V I A : J u g o s l o , · e n s k a K n J i p . T e r a 1 1 j e 2 7 / 1 1 , 1 1 0 0 0 B r u : , R A O E L . E B A S O N : T h e l ~ a n t O i , t r i h u t o r s C o . S A R L . B o • 1 1 8 1 , M a k d a s s i 7 . A I R E : L i b r a i r i e u n i v e r s i t a i r e . a v e n u e d ~ l a P a i • N • 1 6 7 , B . P . 1 6 8 2 , i i S t r e e t . H a n n a B l d g . B E I R L T K " - s H A S A I ! p e c i a l t e r m s f o r d e v e l o p i n g c o u n t r i e s a r e o b t a i n a b l e o n a p p l i c a t i o n t o t h e W H O P r o g r a m m e C o o r d i n a t o r s o r W H O e g i o n a l O f f i c e s l i s t e d a b o v e o r t o t h e W o r l d H e a l t h O r g a n i z a t i o n . D i s t r i b u t i o n a n d S a l e s S e r v i c e , 1 2 1 1 G e n e v a 2 7 , S w i t - e r l a n d . O r d e r s f r o m c o u n t r i e s w h e r e s a l e s a g e n t s h a v e n o t y e t b e e n a p p o i n t e d m a y a l s o b e s e n t t o t h e C . . - . . . . _ , i > u t m u s t b e p a i d f o r i n p o u n d s s t e r l i n g , U S d o l l a r s , o r S w i s s f r a n c s . P r i c e : S w . f r . 1 9 . - P r i c e s a r e s u b j e c t t o c h a n g e w i l h o w t f t C f f l e 9 . C / 1 / 8 4 I n m o s t o f t h e c o u n t r i e s o f t h e W H O E u r o p e a n R e g i o n t h e y e a n s i n c e t h e S e c o n d W o r l d W a r h a v e b e e n m a r k e d b y a p r o g r e s s i v e l i b e r a l i z a t i o n o f t h e r e l a t i o n s h i p s b e t w e e n t h e s e x e s . T h e r e a s o n s f o r t h i s a r e m a n y - a m o n g t h e m t h e r a p i d s o c i a l c h a n g e s i n t h e p o s t - w a r p e r i o d , t h e e x p a n s i o n o f f e m i n i s m , a n d t h e r e a d y a v a i l a b i l i t y o f ( e s p e c i a l l y o r a l ) c o n t r a c e p t i v e s - a n d t h e c o n s e q u e n c e s w i l l l e a d t o m a n y t y p e s o f c h a n g e , n o t o n l y f o r i n d i v i d u a l f a m i l i e s b u t f o r c o m m u n i t i e s a n d n a t i o n s . Y o u n g p e o p l e a r e d e e p l y a f f e c t e d b y t h e s e c h a n g e s . T h e y a r e l e s s b o u n d b y t r a d i t i o n a l v a l u e s a n d m o r a l i t y t h a n t h e i r p a r e n t s w e r e , a n d t h e y a r e a w a r e o f t h e g r e a t e r f r e e d o m t h a t t h e y n o w h a v e . B u t t o w h a t e x t e n t h a v e t h e y r e c e i v e d a n e d u c a t i o n i n s e x a n d f a m i l y l i f e t h a t w i l l e n a b l e t h e m t o a v o i d t h e p i t f a l l s o f s u c h f r e e d o m ? A r e g o v e m m e n t s c o n s c i o u s o f t h e p r o b l e m s a n d , i f t h e y a r e , w h a t s t e p s a r e t h e y t a k i n g t o m e e t t h e m ? I f g o v e m m e n t s a r e n o t t a k i n g a c t i o n , d o o t h e r o r g a n i z a t i o n s f i l l t h e g a p ? T o c l a r i f y t h e s i t u a t i o n i n t h e R e g i o n , W H O c o m m i s s i o n e d t h e a u t h o r t o c a r r y o u t a s t u d y o f t h e f a m i l y p l a n n i n g a n d s e x e d u c a t i o n o f y o u n g p e o p l e . T h e r e s u l t s o f t h e s t u d y a r e c l e a r l y a p p l i c a b l e n o t o n l y t o t h e W H O E u r o p e a n R e g i o n b u t a l s o t o m a n y o t h e r p a r t s o f t h e w o r l d . I t i s t o b e h o p e d t h a t g o v e m m e n t s w i l l e x a m i n e t h e f i n d i n p w i t h c a r e i f o n l y b e c a u s e , a s t h e s t u d y p o i n t s o u t , i t i s c h e a p e r t o p r o v i d e t h e y o u n g w i t h a d e q u a t e e d u c a t i o n o n f a m i l y p l a n n i n g a n d s e x t h a n t o c o p e w i t h t h e a b o r t i o n s , r u i n e d e d u c a t i o n a l o p p o r t u n i t i e s a n d o t h e r u n w e l c o m e s i d e e f f e c t s o f t o d a y ' s s e x u a l f r e e d o m .