Healthy Respect Practitioners Network Event Methodist Church June 14th, 2018

Welcome and Introduction Yvonne Kerr Assistant Programme Manager, NHS Lothian Yvonne.Kerr@nhslothian.scot.nhs.uk

Healthy Respect Update What we do: Facilitate professional networks Provide training and development for professionals Improve access to young people’s services Develop resources for professionals and young people Involve and advocate for young people Influence policy to support culture change

New national resource for 3-18 year olds https://rshp.scot/

LD/ASN Training Aiming to provide: 2 LD/ASN full day training modules to be completed after CORE training (25th Sept. & 4th Dec. 2018). A series of shorter sessions (2 – 3 hours) focussing in depth on specific issues (TBA) LD / ASN & Sexual Health background Gender, sexuality and sexual expression Puberty Law & Policy Relationships CP / CSE / ASP Sexual development & behaviour Rights, Values & Attitudes Resources Capacity & Consent Parenthood Sex and the internet

Mojca Becaj get2gether Karen Sutherland get2gether Ambassador Andrew Hiddleston get2gether Ambassador

An investigation into the dating and relationship experiences of adults with Asperger's syndrome Hannah Murray

Why might people with AS experience sexual inequalities? Individuals with a diagnosis of AS experience varying difficulties in areas of social interaction, social communication and flexibility of thought (and also sensory processing difficulties). As AS does not have any physical characteristics, it can often go unnoticed, and undiagnosed. Individuals with AS are then often seen as just ‘unusual’ or ‘aloof’ as peers are unable to recognise any specific needs that they may have. The very foundations of forming and sustaining any relationship relies on social ability. Inherent difficulties with interaction and communication can limit social experiences and can often result in Individuals with AS finding themselves on the outskirts of social circles. This leads to a lack of social understanding which can leave them unprepared for romantic relationships.

Masters research project ‘An investigation into the dating and relationship experiences of adults with Asperger’s Syndrome’ Adults with AS were given the opportunity to take part through either an online questionnaire or interview, and were asked a wide range of open-ended questions to gather their uncensored thoughts and opinions about their experiences of dating and relationships.

Difficulties initiating relationships Three main results Difficulties initiating relationships Negative experiences Lack of education

Initiating relationships Half of the participants highlighted that they find it difficult to recognise when someone is flirting with them, or were not sure how to flirt with someone that they liked Many participants also described how they ‘did not know’ how to appropriately communicate. This included areas such as ‘knowing the right kind of questions to ask’, and ‘knowing when to change topic’ as well as difficulties recognising and appropriately using gestures and facial expressions. A number admitted that they are not fully aware of the social etiquette or ‘rules’ of dating, one saying: ‘I don’t understand 90% of how it works’.

Negative experiences Almost half admitted they have experienced rejection when attempting to meet a partner. For many, this led to a lack of confidence and increased anxiety levels – resulting in then being unwilling to initiate the first move again. When asked the effects that dating can have on their emotional wellbeing, many of the words that the participants used were negative – such as ‘draining’, ‘stress’, ‘difficult’ and ‘sad’. 50% said that they had not felt unsafe or at risk when dating, the other 50% either passed, or said that they had experienced harmful situations. Two participants had been victims of sexual abuse, and a further three highlighted situations where they had said ’no’ to advances from someone else, but were initially ignored.

Victims of sexual abuse In a 2006 study, Murphy & Elias found that children with developmental disabilities were 2.2 times higher to be victims of sexual abuse than those without a disability Reasons why people with AS/ASD could be at higher risk of being a victim of sexual abuse - Lack of sexual knowledge - Limited peer relationships - Low self-esteem leading to poor character judgement & a higher possibility of choosing an abusive partner - Inability to notice or understand negative intentions - Limited communication skills - Difficulty recognizing what is and is not abusive - A desire to be socially accepted - Demonstrating behaviours which could be misconstrued as sexually inviting or provocative - Lack of people with whom they can talk

Committing sexual abuse Sutton et al. (2013) carried out an assessment of 37 male adolescents within the criminal justice system for sexual offending and who were undergoing treatment, and found that 22 participants (60%) met the diagnostic criteria for an Autism Spectrum Disorder. Reasons why people with AS/ASD could be at higher risk of committing sexual abuse - Social impairments - Desire for attachment - Impaired Theory of Mind - Persistent preoccupation (’obsessions’) - Tendency to engage in private sexual behaviours in public - Less sex education - Lack of awareness about what is legal/illegal - Misconstrued sensory behaviours - Difficulties reading facial expressions or body language

Lack of education All but two participants (89.47%) stated that they did not feel that they received adequate education to prepare them for their romantic experiences. Only one said that they received the majority of their education from school and the rest received most of their information from movies/film/the internet, and also from parents or friends. When asked to list the weaknesses of the education that they received, the majority highlighted that their ‘sparse’ education only covered basic physical elements such as condom use and STI’s, and no social or emotional factors. Six also admitted (unprompted) that they did not receive any education about consent.

Consent Individuals with AS/ASD may innately possess less skills in obtaining/giving sexual consent. Difficulties in understanding gestures and facial expressions may make it more challenging for someone to ‘take the hint’ that someone is not interested. A very literal understanding of language, or not picking up on the subtleties in social communication, can lead to the misconception that someone has given consent, even if they have not. They may not be able to recognise dangerous or harmful situations, and may not have the ability to say ‘no’. Pressure to adhere to social conventions/appear ‘normal’ may result in situations which they feel are expected of them (ie. allowing a stranger to buy them a drink or invite someone into their home after a date)

Moving forwards Taking into account the reflections and experiences from those with Asperger’s Syndrome, it is clear that there is a lack of appropriate education and support to reflect their needs. From the youngest age possible, and across a range of different sources, thorough education should be provided which covers not only physical, but social aspects of sexual wellbeing. Support should be available at every age, and should be available to not only the person with the diagnosis, but also parents, teachers, carers etc. to ensure that there are no gaps and nobody is left behind.

Helpful resources Useful written accounts by AS authors - ‘Love, sex and long-term relationships: What people with Asperger Syndrome really, really want’ by Sarah Hendrickx - ’Autism-Aspergers & sexuality: Puberty & beyond’ by Mary & Jerry Newport - ‘Love, partnership or singleton on the Autism Spectrum’ edited by Luke Beardon & Dean Worton Resources for practitioners - ‘Asperger’s Syndrome: From adolescence through adulthood’ by Isabelle Hénault - ’Intimate relationships and sexual health: A curriculum for teaching adolescents/adults with High Functioning Autism Spectrum Disorders and other social challenges’ by Catherine Davis & Melissa Dubie A very useful podcast - Conversations 30/11/17 – ‘Love and family and Asperger’s: Tony Attwood’

Any questions? hannahjmurray@outlook.com

Tea, coffee and networking

Sexual Health and Homelessness Rebecca Dey Health Promotion Specialist NHS Lothian

34,864 Homeless applications in Scotland between 2016-2017 (Scottish Gov, 2017) Between September 2016 and September 2017, over 34,000 homeless applications were made in Scotland. An increase of 118 applications from the previous year. However the introduction of the housing options model can be said to have contributed towards the decline of homeless applications since 2010. http://www.gov.scot/Resource/0053/00530316.pdf

Health Inequalities are Health Inequalities are... “The unfair and avoidable differences in people’s health across social groups and between different population groups” (NHS Scotland, 2016, p.6)

73% of homeless people reported a physical health problem 80% were experiencing some form of mental health issue (homeless link, 2014)

WHAT’S MISSING?

THE VULNERABLE VICTIM

“Women shouldn't have to put themselves in danger to secure a place to stay, blurring consent by entering a space where someone else has all of the power. Women shouldn't have to fuck their way out of precarity” (Moyes, The National, 2017)

“The prevailing societal view of what constitutes masculinity makes it difficult for men to identify themselves as experiencing abuse and can prevent them from seeking help” (Scottish Government, 2016ᵃ, p.20).

THE DETRIMENTAL EFFECT OF STRUCTURAL FACTORS

“This wage gap has implications that reach far beyond women's bank balances” (Burns, The National, 2017)

“Along with their gender, women and girls have other protected characteristics that increase their level of risk of experiencing violence and abuse. Drivers for this are often the continuing prejudice and structural barriers in society which cause inequality” (Scottish Government, 2016, p.19).

THE RISKS ASSOCIATED WITH DESTITUTION

“Hundreds of refugee women in Scotland are facing "inhumane and unacceptable" exploitation, including being forced into prostitution and domestic servitude, leaving them despairing and suicidal.” (Goodwin, The Sunday Herald, 2016)

“Destitution is harmful “Destitution is harmful. It further traumatises people, makes them more vulnerable to exploitation and increases health issues” (Scottish Parliament, 2017ᵇ, 8, p.1).

HETERONORMATIVE DISCOURSE

“All too often the women's stories of how they ended up here will start with: "Well, I met this man” (Allan, The Sunday Herald, 2016).

“Young LGBT people are thought to be over- represented among the homeless, and to be particularly vulnerable” (Scottish Government, 2013, p.5).

SO WHAT? Health needs assessment: A health needs assessment can be defined as ‘a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities’ (NICE), National Institute for Clinical Excellence. Health Needs Assessment. A Practical Guide. Knowledge for Health. [Online] 2005. [Cited: June 05, 2017.]https://www.k4health.org/sites/default/files/migrated_toolkit_files/Health_Needs_Assessment_A_Practical_Guide.pdf

STRUCTURE AND AGENCY THE ROLE OF THE MEDIA SOCIAL EXCLUSION GENDER

NOW WHAT?

HEALTH NEEDS ASSESSMENT “A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities” (NICE, 2005) Health needs assessment: A health needs assessment can be defined as ‘a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities’ (NICE), National Institute for Clinical Excellence. Health Needs Assessment. A Practical Guide. Knowledge for Health. [Online] 2005. [Cited: June 05, 2017.]https://www.k4health.org/sites/default/files/migrated_toolkit_files/Health_Needs_Assessment_A_Practical_Guide.pdf

Sex work Homelessness INCLUSION HEALTH = Criminal Justice Substance misuse

Characteristics of Target Population Common adverse childhood experiences and risk factors eg: poverty and childhood trauma. Extremely poor health, multiple morbidity and early mortality (Aldridge, Story and Hwang et al, 2017) Numerous barriers to accessing health services (Elwell-Sutton et al, 2017) Inclusion health is a research, service, and policy agenda that aims to prevent and redress health and social inequities among people in extremely poor health due to poverty, marginalisation, and multimorbidity. The association between socioeconomic status and health outcomes is well established. However, these commonly observed social gradients in health do not capture the full extent of health inequities for individuals who experience considerable social exclusion.   Previous research has described the high prevalence of substance use disorders in homeless populations, prisoners, and sex workers, and the increased prevalence of homelessness in prisoners and sex workers. These marginalised populations have common intersecting characteristics and adverse life experiences that lead to considerable social exclusion, making them powerful determinants of marginalisation in high-income settings. (Aldridge)

WHAT CAN WE DO TO HELP? Women only spaces Accompanied appointments Co-location and Outreach Training Information Trauma Aware Services Privacy

Accompanied Appointments Co-location and Outreach Women only spaces Accompanied Appointments Co-location and Outreach

Sexual health for Adults and Vulnerable Groups Training Information Sexual health for Adults and Vulnerable Groups Making Choices Keeping Safe: Sexual health for Adults with Learning Disabilities

Trauma Aware Services Privacy

OVER TO YOU... Rebecca.Dey@nhslothian.scot.nhs.uk QUESTIONS COMMENTS DISCUSSION Rebecca.Dey@nhslothian.scot.nhs.uk

REFERENCES Scottish Government. (2017). Homelessness in Scotland: 2016-17. [Online] Available from: file:///C:/Users/s1030604/Downloads/00521186.pdf [Accessed 5th September 2017]. NHS Health Scotland. (2016). Health and Homelessness: Inequality briefing. [Online] Available from: http://www.healthscotland.scot/media/1251/health-andhomelessness_ nov2016_english.pdf [Access 12th June 2017]. Homeless Link. (2014). The unhealthy state of homelessness: Health audit results. 2014. Homeless Link: London. Vonny Moyes: Why sex for rent is not a deal like any other. The National. April 17 2017. Vonny Moyes Scottish Government. (2016ᵃ). Equally safe: Scotland’s strategy for preventing and eradicating violence against women and girls. [Online] Available from: http://www.gov.scot/Resource/0049/00498256.pdf [Accessed 17th July 2017] Zero Tolerance on low pay for women. The National. March 28 2017. Janice Burns Scottish Government. (2013). Equality Outcomes: Lesbian, Gay, Bisexual and Transgender (LGBT) Evidence Review. [Online] Available from: http://www.gov.scot/Resource/0042/00420922.pdf [Accessed 17th July 2017] Luchenski, S., et al. (2018) "What works in inclusion health: overview of effective interventions for marginalised and excluded populations.“ The Lancet

Discussion Groups Aspergers/ASD/Learning Disabilities Homelessness Transgender Choose one inequality and focus on: What are the barriers and challenges for this group accessing sexual health services, information and education What can we do about this/ What is good practice? One key action you will take back to your work place

Supporting Transgender young people. Guidance for Schools in Scotland Ann Marriott Partnership Manager (East)

Programme LGBT Youth Scotland Statistics Supporting transgender young people in Scottish Schools Scenarios What can you do?

Who are LGBT Youth Scotland? A national youth organisation, established in 1989 Our mission is to play a leading role in the provision of quality youth work to LGBTI young people that promotes their health and wellbeing, and to be a valued and influential partner in LGBTI equality and human rights

LGBT Youth Scotland Youth groups held in Leith One to one support Working with schools and youth groups Sharing best practice Range of resources

Why are we doing this? Quiz "Our new Life in Scotland report captures a snapshot of what it’s like to be an LGBT young person growing-up in Scotland today. The findings of this year’s report show that some experiences have changed, but not all in a positive direction. While a high proportion of respondents believe that Scotland is a good place to grow up, there are young people in rural areas that don't share that view. Sadly, transgender young people continue to face significant prejudice and discrimination and experience the highest rates of bullying and hate crime. The report shows how far we have come but highlights the continued need for attention to the experiences of bullying at school and suicidal feelings amongst LGBT young people."  

50% of all LGBT young people are bullied at school. Higher/Lower? 71% of LGBT young people experienced bullying in school on the grounds of being LGBT. This is a rise from 69% in 2012 and 60% in 2007.

25% of LGBT people leave education as a result of homophobia, biphobia and transphobia Higher/Lower? 2018 9% of LGBT young people and 27% of transgender young people left education as result of homophobia, biphobia and transphobia in the learning environment.

75% of LGBT people indicated that they had experienced mental health problems and associated behaviours Higher/Lower? 84% of LGBT young people, and 100% of transgender young people, indicated that they had experienced mental health problems and associated behaviours.

50% of LGBT young people experienced suicidal thoughts or behaviours Higher/Lower? Half (50%) of LGBT young people and 63% of transgender young people experienced suicidal thoughts or behaviours.

Noting the statistics within the quiz allows us to consider equality vs equity. This slide clearly shows that in the first image 3 people watching a game are standing on boxes of equal size, howeverone person cannot see. The second image shows that providing additional support all three people can see The third image shows us that by removing all barriers, all people can see. The aim would be for the fence to be removed altogether, so the people could play as well

Scenarios

What can I do? Use a person-centred approach Don’t make assumptions Challenge stigma Ensure LGBT visibility across your service Review policies and forms to ensure they are inclusive Learn more and share learning

Any questions?

lgbtyouth.org.uk Nigel.chipps@lgbtyouth.org.uk

The Team Contact Us: www.healthyrespect.co.uk Yvonne Kerr - Assistant Programme Manager, Sexual Health and BBV) Steff Kaye - Services Coordinator Rachel Barr – Senior Health Promotion Specialist Leanne Rockingham – Network Officer Mark Baillie – c:card Manager Diane Lee – Health Promotion Specialist (Education) Louise Queen – Health Promotion Specialist (Education – Learning Disabilities/ASN) Carol Cahill – Administrative Secretary Contact Us: www.healthyrespect.co.uk healthy.respect@nhslothian.scot.nhs.uk