B
BUDDSBarnet Unified Document
for Down Syndrome

Puberty, Contraception, Sex and Relationships

Comprehensive sex and relationship education guidance for schools and parents, including puberty preparation, teaching resources, and support materials

Introduction

Do school policies for social and relationship education really meet the needs of pupils, asks Head David Stewart, and what happens in the real world of the classroom?

(David S Stewart OBE is Head Teacher of Shepherd School, Nottingham and Head Teacher Designate of Oak Field School. He is also a member of the PSHE Association, the subject association for all professionals working in personal, social and health education).

Every child, whether they are in a mainstream or special educational setting, has a right to a sex and relationship education (SRE) which supports them and prepares them for the realities of life. Parents of children with additional needs have identified that they wish schools to work with them on what is seen as a difficult aspect of their child's life. Citizenship education assumes that young people have a good grasp of self-worth and respect for others, and anti-discrimination legislation demands that pupils with special needs are not disadvantaged in terms of access to the full curriculum. While there may seem to be no shortage of reasons to ensure that these pupils receive appropriate SRE education, evidence suggests that the reality is very patchy.

Small-scale research in individual authorities paints a picture of very mixed practice. There is no doubt that in some schools there will be exemplary practice. However, this is often down to a particular member of staff who is passionate about SRE. What happens if they leave or retire? Is the whole school signed up to this education?

In other schools, both special and mainstream, some pupils appear to receive almost nothing at all; it is not uncommon to hear comments such as "It is difficult for us to discuss issues such as masturbation being a faith school." Some schools might have a written policy but no clear guidance on who is teaching what. So often, the role of covering SRE is given to teaching assistants who may have had no training in special education or sex education. Even if they have been on training courses, they have no authority in the school to change practice or timetabling.

Staff often identify a lack of resources or training as key problems, and there can also be a lack of support from senior leadership. Governors who have a responsibility for this area of the curriculum may not question what is being provided for pupils with additional needs. While there is every hope that future OFSTED inspections will question access for all pupils, I think there are some key areas for schools to consider now:

  • Does the SRE policy reflect all the needs of pupils? There are many situations in school which are not necessarily covered by the policy, so how are these monitored and assessed? For instance, with issues of personal and intimate care, staff may have a degree of uncertainty about what is deemed appropriate. Are behaviours excused due to disability? There can be a real danger that pupils are not provided with the appropriate boundaries.
  • Rather than working in isolation, schools should set up support groups including relevant agencies and individuals. Indeed, for 25 years, my school has had a sex and relationship monitoring group. Members include staff, governors, parents, and colleagues from health, police and educational psychology. They work with staff on the delivery of the education and provide training for parents on a wide range of issues. They have also produced a series of booklets for pupils and parents to support their work.
  • When should sex and relationship education begin? In the early years, children should be given clear guidance about dignity and modesty, and they need to have a suitable vocabulary to help them understand their bodies. At this age, opportunities to make choices must be introduced. They need to know that they can say no. From an early age, children need to develop the skills which will help them keep safe. If they are not encouraged to do this, what happens when they find themselves in a problematic situation at age sixteen and they do not have the skills to make decisions and be assertive?
  • Working with parents is essential. If one is talking about masturbation being a private activity, i.e. in the young person's bedroom, then discussion with parents is essential. Parents often feel isolated concerning this area of their child's life, and this is a topic they feel less inclined to talk to other parents about. They need a forum where they can feel comfortable and realise that there are other parents who are dealing with similar issues and can often offer support and advice.
  • There is a need for ongoing training and professional development. I would always recommend a general all-staff training to begin with. While many staff members may not be involved in direct teaching of SRE, they will encounter a wide range of issues during the course of the school day, and their reactions and responses to situations can be as powerful as formal teaching. If it has been agreed that a pupil should be dealt with in a particular way, then all staff need to have signed up to this. Staff will have a wide range of views, but they also have a duty to support the pupil with appropriate education. Too often, schools simply respond to a crisis rather than having thought through possible scenarios and appropriate responses in advance.
  • Education should be prophylactic. Pupils need to understand what is happening to them as they grow up. Social stories which prepare for periods or wet dreams can dispel a great deal of anxiety. For those pupils who dislike change, the changes of adolescence can be particularly traumatic.
  • Issues of friendships and relationships need very sensitive handling, and young people need to know what the social rules are. Children with additional needs can feel very isolated and have little opportunity for friendship, let alone relationships. While responsibility for this area of a child's life is not just the school's, clearly, a school is in a good position to support pupils in the development of friendships.

This is not an area of choice for schools; it is one of absolute duty. Schools must support some of the most vulnerable children and young people in society and help them to have happy, safe and fulfilled lives.

Further Information

A series of information booklets for parents on:

  • Menstruation § Male Masturbation.
  • Female Masturbation.
  • HIV & AIDS.
  • Protecting Your Child.
  • A Planned Dependent Life & Sexuality.
  • Loss (also suitable for younger children).
  • Smearing.
  • Your Child's Right (An introduction to Sex Education for parents).
  • Your Child's Right 2 - FAQ.

Booklets for young people on "Feeling Grown Up":

  • Female Masturbation.
  • Male Masturbation.
  • Menstruation at Home.
  • Menstruation at School.
  • Wet Dreams.
  • Use of Public Toilets.

All booklets are £3.00 each plus postage & packaging. Click here for the booklet order form and here for a list of PSHE resources on the Oak Field School site. Tel: 0115 915 3265. Email: admin@oakfield.nottingham.sch.uk.

Periods/Menses

Preparation is key

It's advisable not to wait until your daughter gets her first bleed before you talk to her about periods. Girls can begin their periods from the age of 9 and sometimes earlier. It is, therefore, important to have an ongoing conversation about changes to her body, such as her growing taller, needing to buy new clothes and her body shape changing. This will lay the foundation for talking to her about beginning her period. Discussing menstruation before it happens reduces levels of anxiety and avoids it seeming like a crisis or a scary event when it does happen. Talk to your daughter's school and ask them what they teach and how they teach the subject of puberty and menstruation. This can be useful for both you as the parent and the school, so together you can educate your daughter in a structured way that she will understand. After your daughter begins her period, preparation is still important. Keeping a diary of her menstrual cycle can help to plan, allowing you both to be prepared emotionally and practically for her monthly bleed.

How can period pants help?

It can be a worry as a parent how your daughter will cope with changing her period protection, especially if she is at school or without you. It may be that your daughter is also anxious about changing and disposing of a pad or tampon in a public bathroom. WUKA's Period Pants can be worn up to 8 hours on lighter days, meaning that your daughter may not need to change her pants whilst out and about. Some girls may find a pad irritating against their skin, especially those who may have sensory issues. Wearing WUKA's Period Pants (or similar "period pants") alleviates the above concerns as the pad is secure inside the pants, meaning that they fit and feel like a pair of ordinary pants. They are made from soft, breathable and moisture-wicking materials which contain no harmful chemicals.

Many parents of girls with developmental delay or learning disability worry about the time when their daughter starts their period. Common concerns include how your daughter will cope with the blood, concerns around cleanliness, and difficulties for carers looking after the young person. This leaflet aims to answer commonly asked questions around this.

Resouces

Can my daughter's puberty be stopped?

Treatment to stop puberty is available for girls who enter puberty abnormally early. In the UK, puberty starts any time after 8 years. At first, breast buds appear, and 18 months, 2 years later, the periods start; therefore, it would not be considered usual for periods to start before 10 years.

This treatment involves a monthly injection and switches off all of the teenage hormones that come from the brain. This is associated with potential side effects, so this treatment can only be used for a defined period of time. To use it for longer would have adverse effects on bone health.

It is important to note that a normal puberty is crucial for the development of healthy bones as an adult. We build up our adult bone strength between the ages of puberty and 30. Oestrogen plays a vital role in this. Many adults with disability have weak bones, which can be due to several reasons; for example, some antiepileptic drugs, the effects of not weight bearing. Therefore, it is even more important that we protect the bone health of this population.

Most young people with disability benefit from a regular vitamin D supplement. Please ask your doctor about this.

So what can be done to help my daughter and family cope with periods?

The best option is to wait and see what happens when they start. Many girls surprise us by coping well with periods. At first, periods may be quite light or infrequent and are easier to cope with than full adult periods. Once periods start, if they are causing difficulties, then there are several medical options available to make them less frequent, lighter or stop them altogether.

Intrauterine system/Mirena coil

This is a highly effective method of stopping periods or lightening heavy periods. 40% will be without periods after 1 year of use. Once inserted, it often takes several months to stop the periods and bleeding during this time can be irregular. The POP or COCP can be used in addition in the short term to treat this. You do not need to have had children previously to have a coil inserted, but it might feel uncomfortable, and so this is a short procedure done under general anaesthetic for our young people with learning disability.

Mirena coil is not suitable for: People who are at high risk of anaemia.

Contraceptive Implant/Nexplanon

This is a small, flexible plastic rod that is inserted below the skin in the upper arm. It releases Progesterone over 3 years. It is associated with irregular bleeding and therefore should not be considered as 1st line.

Contraceptive injection/Depo-Provera

This is a high-dose Progesterone injection that lasts 3 months. It is associated with irregular bleeding and a reduction in bone density; therefore, it is not recommended in adolescents.

Depo-Provera injection is not suitable for: Patients under 18 years of age.

Progesterone only pill/POP/"the mini pill"

Progesterone can be taken in many forms, as a tablet, injection, implant or intrauterine coil. In general, we would advise the tablet form as first line, as the injectable forms are difficult to reverse and have more impact on bone health. The POP is to be taken once daily, continuously. The dose can be doubled if bleeding persists.

Combined Oral Contraceptive Pill / COCP / "the pill"

This contains Oestrogen and Progesterone; historically, it was prescribed as 21 tablets and then a 7-day hormone-free interval, when bleeding is expected. Nowadays, it is safe and recommended to take multiple ways:

  • Shorten the hormone-free interval to 4 days to shorten the length of the period.
  • Take 3 packets "back-to-back" with a 4-day break, this is called "tricycling", resulting in 4 periods a year.
  • Continuous use until breakthrough bleeding, and then have a 4-day hormone-free interval.

There are many different options, including low-dose Oestrogen COCP. The Oestrogen component is associated with an increased risk of blood clots, heart attacks and stroke; therefore, medical history and risk factors must be considered.

COCP is not suitable for:

  • Young people who are wheelchair bound.
  • History of migraine with aura.
  • Personal or strong family history of blood clots and BMI >35kg/m2.

Resources for Further Information

Resources for Further Information - For Professionals

Genital Examination Resources

Other Resources