Chapter 5Improving literacy and enhancing employee rights
Sexual and reproductive health literacy
5.1Health literacy relates to how people access, understand, and use health information in ways to benefit their health. According to the Department of Health and Aged Care (the Department), when individuals have a lower health literacy, they are at a higher risk of worse health outcomes and poorer health behaviours. As such, improving health literacy is recognised as a key element in encouraging individuals to engage with health professionals.
5.2Submitters highlighted that sexual and reproductive health literacy was important from early childhood onwards in order to provide comprehensive and practical information to individuals to empower them to make informed, safe and autonomous decisions about their health. They emphasised that all Australians needed to have access to accurate sexual and reproductive health information, delivered in an age-appropriate, inclusive and culturally safe manner, that was relevant for the specific needs of diverse cohorts across the population.
5.3The following section will cover the levels of sexual and reproductive health literacy in the Australian community and some of the barriers to sexual and reproductive health literacy raised by submitters, including:
the adequacy of the sexual and reproductive health education taught in schools; and
the opportunity for tailored sexual and reproductive health education strategies to better reach diverse cohorts across the Australian population.
Current state of sexual and reproductive health literacy in Australia
5.4The committee heard evidence indicating that the sexual and reproductive health literacy of Australians was generally poor. For example, DrJacquiHendriks, Founder of Bloom-ED, an alliance of teachers, researchers, students, parents and organisations that advocates for improved sexual and reproductive health literacy, described the situation:
Universally, the sexual health literacy of Australians is incredibly poor. For many of us, sex, sexuality and issues of sexual and reproductive health are associated with personal embarrassment, shame, stigma or general ignorance. As a society, we don't often speak about sex in an open or a genuine way. We also can't assume the health services will bridge this gap as their workforce development is often grossly inadequate. The very fact that such a central aspect of being human is often ignored or is addressed superficially greatly impacts our individual and collective abilities to understand, access and use health information or to navigate services.
5.5cohealth, one of Australia's largest community health organisations which delivers care across Melbourne and greater Victoria, provided the committee with a specific example demonstrating the lack of sexual and reproductive health literacy among the population. It advised that its practitioners regularly observed the impact of people relying on social media for their health information, resulting in misinformation and misconceptions about various forms of contraception. It noted that a significant part of the work of its Sexual and Reproductive Health Hub was educating people on the facts about contraception, and correcting negative views heard via hearsay and social media.
The adequacy of the sexual and reproductive health education taught in schools
5.6Some submitters made particular comment on the inadequacy of the sexual and reproductive health education taught in Australian schools and the flow-on impact this had on the health literacy of young people and the broader community.
5.7Although state and territory government and non-government education authorities are responsible for the administration and operation of schools within their jurisdictions, age‑appropriate sexual education is part of Australia's national curriculum. The Department stated that this curriculum sets the expectations of what all Australian students should be taught, regardless of their geographic location or background.
5.8The Australian National University Law Reform and Social Justice Research Hub (ANU Hub) advised that to a large extent, sexual health literacy in Australia was 'decentralised'. It explained:
The most salient period of sexual health education occurs at the primary and secondary schooling period. While the Australian Curriculum and Reporting Agency (ACARA) curriculum is accepted by all jurisdictions, each state and territory retains significant authority over that which is taught to students in their jurisdiction. Furthermore, there are a range of provisions per state/territory allowing private and/or religious schools to offer different information to students on sexual and reproductive health.
5.9The ANU Hub noted that despite the emphasis on sex education in each state and territory, there remained 'worrying signs' regarding the knowledge and understanding of Australian students. It reported that in qualitative reviews, many students recounted the irrelevance of the information they were taught at school, a sentiment particularly shared by members of the LGBTIQA+ community. Ms Jordina Quain, the Education Director of the Sexuality Education Counselling Consultancy Agency, describing the majority of school-based relationships education as 'too little, too late, and too straight.'
5.10Furthermore, the ANU Hub said that quantitative data demonstrated a moderate to low level of knowledge of Sexually Transmitted Illnesses (STIs) and the risks of unprotected sex. It advised that the inconsistent application of sex education across private and/or religious schools posed a problem for general sexual literacy.
5.11The Fay Gale Centre for Research on Gender at the University of Adelaide (Fay Gale Centre) stated that a lack of comprehensive sex education was a contributor to poor reproductive health outcomes, including unintended pregnancy.
5.12It observed that while Australia had an existing national curriculum that endorsed sexuality and relationships education through a positive strengths-based approach (drawing on the World Health Organisation's definition of sexuality), how this was implemented and the content that students had access to varied greatly.
5.13The Australian Nursing and Midwifery Federation (ANMF) also informed the committee that the quality of sexual and reproductive health literacy programs varied greatly within schools. It detailed:
Initiatives such as Respectful Relationships and Safe Schools are a good start for improving family violence and LGBTQI+ safety within schools, but they are not dedicated to sexual or reproductive health. As such, schools are left having to bring in outside assistance or teach it themselves. Rural schools are likely to face greater difficulty in accessing sexual health nurses or health promotion officers due to geographic distance from providers.
5.14Bloom-ED raised concerns with the Australian curriculum, arguing that it still failed to ensure adequate sexual and reproductive health education for students. It detailed:
You will struggle to find critical terms such as sex, sexuality, puberty, menstruation, pregnancy, abortion, contraception, sexually transmissible infection or pornography in these documents. If they do exist, they sit in the glossary or in the areas of the curriculum that are optional. There is also no requirement for a young person to learn about human reproduction, to learn how their own reproductive system works and how they are potentially capable of pregnancy.
5.15Ms Lucy Peach, a professional educator on the menstrual cycle, in particular highlighted the lack of focus on menstruation in the health curriculum. She noted that this was a disservice to all students:
I also think it's really important for boys, people without periods and men to understand the workings of bodies that are different to their own. Until we have men and boys on board we're not going to be able to progress, because I think it's a really important piece of gender equity.
The importance of comprehensive sexuality and relationships education
5.16The Family Planning Alliance Australia (FPAA) , the peak body for reproductive and sexual health services, informed the committee of the importance of comprehensive sexuality education (CSE) provided through schools, communities and families, given that, if properly done it offered young people a solid foundation to develop lifelong sexual and reproductive health literacy. However, it identified that there were a number of barriers to achieving this via the current Australian curriculum. For example:
While the curriculum includes components of CSE, the guidelines are 'ambiguous, open to interpretation and omit key topics'.
While research shows that Australian young people perceive school-based CSE as valuable, the inclusion, quality and relevance of the teaching is inconsistent. This may be attributed to the lack of specific CSE guidelines within the curriculum, as well as a deficit in teacher skills and confidence, the absence of school policies, or a non-supportive school culture.
5.17The Fay Gale Centre also drew the committee's attention to the concept of comprehensive sexuality and relationships education (CSRE) as a curriculum-based process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It noted that CSRE is age-appropriate and emphasises autonomy, safety and respect.
5.18The Fay Gale Centre stated that currently Australian students do not necessarily have access to all components of CSRE. It explained:
Consistently, the biological aspects of reproduction and the health risks of sexual activity are foregrounded in sex education while social and relational aspects are neglected. Thus Australian young people continue to be dissatisfied with the depth of learning available to them through school-based programs and report difficulties in navigating healthy and equitable relationships (with consent being just one aspect of this).
5.19It further advised that as well as inconsistent implementation, current sex education is often heteronormative and excludes LGBTIQA+ and gender diverse people. It argued that this was concerning because of the well-documented harms of not accepting gender and sexual diversity in young people, including poor mental health and elevated risk of suicide.
5.20The Fay Gale Centre posited that access to CSRE was a fundamental human right in relation to sexual health and wellbeing, stating:
The knowledge and understanding that comes from this education is the foundation of reproductive health literacy which is essential for preventing a range of health problems, including coercive sexual encounters, sexually transmitted infections and unplanned pregnancy.
5.21It recommended that CSRE be available to all students through all schools, with the appropriate training of teachers and provision of resources, including external support staff where appropriate.
5.22The FPAA also advocated for the inclusion of CSE within the Australian curriculum and community-based educational programs, with their submission detailing key principles for consideration in program design.
5.23The committee heard that barriers to sexual and reproductive health literacy were more acute in cohorts who were already marginalised or experienced a lack of access to services. Submitters identified the following cohorts as experiencing particular challenges:
geographically rural and remote communities;
young people (particularly girls and young women);
LGBTIQA+ communities;
people living with disability;
culturally and linguistically diverse (CALD) communities (including migrants and refugees); and
First Nations communities.
5.24Evidence relating to four of these cohorts are discussed further below.
First Nations communities
5.25The Institute for Urban Indigenous Health submitted that First Nations communities were at risk of lower health literacy due to factors such as lower school-based literacy and socioeconomic disadvantage across education, employment and income. It noted that this was further exacerbated by a general absence of accessible, evidence-based, culturally appropriate, and age-specific sexual and reproductive health messaging for First Nations people.
5.26The Institute for Urban Indigenous Health recommended that the Government provide targeted funding for sexual and reproductive health messaging and education to increase the health literacy and reproductive autonomy of First Nations communities. It also recommended that the Government work with state and territory counterparts to better integrate and eliminate barrier to delivering culturally-tailored health education and promotion in schools.
5.27The National Aboriginal Community Controlled Health Organisation (NACCHO) also strongly advocated for accurate sexual and reproductive health information provided in a culturally safe way. It detailed:
Awareness campaigns around all aspects of Aboriginal and Torres Strait Islander reproductive health must be appropriately targeted. They must acknowledge the special cultural needs and health gaps experienced by Aboriginal and Torres Strait Islander people. They should explicitly acknowledge the intersectionality of Aboriginal and Torres Strait Islander people and the LGBTQIA2+ community. Where appropriate they should be provided in Aboriginal and Torres Strait Islander languages.
5.28NACCHO recommended sufficient funding for ACCHOs to codesign a wide range of culturally safe information campaigns to address gaps in reproductive health outcomes for First Nations people.
People with disability
5.29The Sexuality Education Counselling Consultancy Agency (SECCA) in Western Australia provides counselling, education and resources in the space of sexuality and disability. It advised that in its experience, people with disability frequently presented to its services with very limited sexual and reproductive health literacy, in large part due to inadequate education at school. Itemphasised that sexual and reproductive health literacy for people with disability needed to be proactive, accurate and properly targeted, at the individual and at their teachers, families, caregivers and support workers.
5.30Dr Emily Casttell, SECCA's Clinical Director explained:
We really see it [appropriate sexual and health education] needs to occur from day 1 right through and at every level. There is a legacy of old ideologies and systems and models that persist today. We see that generationally in our client base as well. Our older clients are still suffering the consequences of very incomplete and harmful education in their early life. It's changing for our younger clients. So we're doing that reactive part, and it just needs to be different from here on out for our young people.
LGBTIQA+ communities
5.31ACON, a national health organisation specialising in community health, inclusion, and HIV responses for people of diverse sexualities and genders, emphasised that comprehensive sexuality education is required to build sexual and reproductive health literacy. However, it submitted that school-based sexuality education was often inadequate for people of diverse genders and sexualities, who are then required to develop this health literacy outside of school settings. It also highlighted that many diverse populations who engage in sexual practices experience particular forms of stigma such as homophobia, transphobia, racism, ableism, and ageism, and that this negatively impacted their access to appropriate literacy resources and services.
5.32ACON recommended the development of comprehensive sexuality education programs that are age-appropriate, evidence-based, inclusive of diversity, and committed to ending all forms of stigma.
5.33Rainbow Families echoed this point and stated that it was vital that sexual and reproductive health information provided by educational and other organisations was framed inclusively in its subject matter and language.
Rural and remote communities and CALD communities
5.34The Rural Doctors Association of Australia pointed out that English language literacy was generally lower in rural and remote areas, with English potentially being the second or third language for people in remote First Nations communities. Given the transmission of health information is heavily dependent on the written word (such as posters, brochures, on web pages or other sources), people who experience difficulties with the English language are therefore likely to have poorer health literacy, including sexual and reproductive health literacy.
5.35The National Rural Health Alliance emphasised the need for literacy resources and services that were multi-disciplinary, place-specific and grounded in co‑design:
It is important that women can access health information that is easy to understand, is trustworthy and culturally appropriate. What works in one rural community may not work in another and what works in metropolitan areas may not be always be appropriate in rural areas.
5.36In terms of CALD communities, the Multicultural Centre for Women's Health suggested that the concept of health literacy needed to extend beyond the practice of just providing in-language resources and culturally appropriate service provision (such as working with interpreters). It argued that for migrant and refugee women and gender diverse people, trust, continuity of care, prevention and education were essential elements of health literacy in order to allow individuals to make informed and empowered healthcare decisions.
5.37The International Student Sexual Health Network (the Network) also told the committee that international students often obtain health information from unreliable resources. The Network suggested that this gap in the health literacy and education of international students in Australia could be addressed by providing education to international students on arrival and for a minimum 12‑month period. They suggested that this education could be delivered in modules that are tied to the curriculum and focus on healthy relationships and addressing service navigation issues. Further, the Network stated that the education modules should be:
… delivered in a very non-text based way. Rather than relying on a high level of English proficiency, it should be using words and symbols from different languages and having it very animated. It takes out stigma when we use animation. We know this from when we're working with young people from refugee and migrant backgrounds and international students.
The importance of improving the inclusiveness of sexual and reproductive health education
5.38Submitters reiterated to the committee the need for improved sexual and reproductive health literacy in Australia, both in school and community settings. They noted that the ongoing taboos and pervasive stigma around sexual and reproductive health issues were a persistent barrier to improved literacy, which in turn negatively impacted on health outcomes.
5.39For example, the ANMF stated while there were many programs targeted at improving sexual and reproductive health literacy in Australia, those programs could only 'go so far' whilst stigma and silence existed around many aspects of sexual and reproductive health across the lifespan. It advocated for the normalisation of sexual and reproductive health needs and increased opportunities for people to explore the options available to them without social stigma and rebuke.
5.40It recommended the use of modern forms of communication (such as podcasts, apps and social media) to bring sexual and reproductive health into everyday conversations and reach diverse groups who may not engage with established health promotion campaigns and techniques.
5.41The Illawarra Women's Centre advised through its work with young people in schools and community settings, it had observed that there was still significant taboo and social stigma around many areas of sexual and reproductive health, including menstruation, sex, pleasure, sexuality and gender, different relationship structures, pregnancy, and abortion. As a result, it made clear that it was imperative that young people not only received accurate information on these matters, but also had opportunities to learn and talk free of judgments.
5.42Ms Lorna Geraghty, Project Coordinator for the Youth Educating Peers (YEP) Project run by the Youth Affairs Council of Western Australia, advocated for a holistic approach to youth sexual health education that was inclusive, approached from a sex-positive angle and co-designed with its intended audience. She outlined:
We advocate at YEP for a holistic approach to youth sexual health education, which provides and includes protective behaviours, digital media literacy, navigating dating and relationships consent, STIs [sexually transmitted infections] and BBVs [blood-borne viruses] testing and treatment, safer sex methods and contraception. It's paramount that this education is inclusive of all bodies, genders and sexualities and that it's delivered in a culturally appropriate manner and co-designed with young people. It needs to be facilitated in a fun, evidence-based, harm reduction focused and trauma informed way by a knowledgeable person with a sex positive approach. This education needs to be delivered both in person, in traditional school settings and places that disengaged SHBBV populations are in community, and online through social media. We advocate for the continuation of peer based education services that also upskill the adults that support these young people.
5.43Ms Peach noted that improved literacy was not just applicable to young people, as often parents or older generations were also mis-or under-informed about what sexual and reproductive health education actually entailed and achieved. She explained:
I think we also need community education for parents because there's still a lot of fear and there's this idea that talking about things encourages behaviours, whereas all the research shows that the more information you get, the later your sexual debut is because you are actually making an informed decision instead of just getting it out of the way. Instead of something that just happens to you, it's something that you're choosing…This conversation is primarily around young people, but, like you said, we've got older generations and parents who missed out on that education as well. So it kind of has to go both ways.
5.44The Australian Federation of Medical Women took the view that sexual and reproductive health literacy should encourage autonomy. In particular, it remarked that young people were most likely to receive their sexual knowledge through peers, media, family and community, and formal education. As a result, education systems should ensure that competing ideologies do not negatively impact delivery of information and knowledge around sexual and reproductive health.
5.45Midwives Australia reported that literacy programs often only received short term funding or tended to be micro-specific in focus. Additionally, within some jurisdictions, consumer organisations and non-government organisations tended to take the lead in projects, rather than government. It argued that appropriate and sustainable funding models were required to increase access to education and information.
Reproductive health leave for employees
5.46The committee heard that there is currently no specific reproductive health leave for employees in Australia. A number of submitters raised this is an issue that needed to be addressed in order to achieve better health and gender equity outcomes for women and expressed general support for the idea of reproductive health leave.
5.47For example, Midwives Australia argued that the lack of reproductive health leave for employees was an entrenched barrier to gender equity in the workplace. It noted that there were many examples of gender-specific health issues that remained unacknowledged in workplaces, which meant women dealt with them privately at great personal cost.
5.48The ANMF informed the committee that women were disproportionately affected by sexual and reproductive healthcare issues, and that women were also more likely to perform caring responsibilities. Given these two factors, women tended to access more personal leave than men to deal with these issues. As a result, compared to their male counterparts, female employees typically ended up with less personal leave available for use in other personal circumstances, such as bereavement or general illness.
5.49The ANMF observed that from the onset of puberty to post-menopause, girls and women deal with sexual and reproductive health conditions that often make it difficult to participate fully in daily activities. It noted that women continue to participate in education, employment and other social or community roles even when unwell due to a number of factors, including the prevalence of a 'soldier-on' mentality, a lack of societal understanding, limited or no flexibility in the workplace, and a pervasive taboo around reproductive health conditions often considered too sensitive or private to share.
5.50The Queensland Nurses and Midwives' Union (QNMU) echoed this point, articulating that for many female employees, experiencing heavy periods and menstrual pain, transitioning through perimenopause and menopause remain taboo experiences that they must 'navigate quietly with minimal support' from their employers. It submitted that this reality contributed to inequitable and unfavourable workplace outcomes compared with employees who did not experience these reproductive health-related issues.
5.51The Australian College of Midwives also pointed out that women who experience pregnancy, menstrual pain, endometriosis, menopause symptoms or require a hysterectomy are disproportionally affected by the requirement to use personal leave to manage these health issues, compared to those who do not.
The benefits of reproductive health leave
5.52Some particular submitters, such as the Australian Capital Territory Council of Social Service, suggested that a way to address this particular gender inequity and create better health outcomes for women, as well as productivity outcomes for employers, was to introduce formal reproductive health leave policies. It said:
Embedding policies supporting reproductive health leave is a progressive step towards gender equity and recognising the significance of reproductive health.
5.53The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) advised that it supported discussions around reproductive health leave being legislated in the National Employment Standards as a universal, protected entitlement.
5.54The FPAA informed the committee that while reproductive health leave was still 'in its infancy' in Australia, it was likely that the number of employers introducing these forms of leave will increase as they look to either differentiate themselves from their competitors. It hoped that once a standard was established and 'employers of choice' provided reproductive health leave entitlements available, other employers would follow suit in order to remain competitive.
5.55The FPAA outlined the various benefits that formal reproductive health leave would bring to employers and employees alike:
There are studies from overseas jurisdictions that demonstrate the productivity losses due to “presenteeism” are greater than those lost to workers taking leave to deal with symptoms associated with reproductive health. Normalising the provision of paid leave for workers who are unable to work due to symptoms associated with reproductive health will be good for workers and good for productivity.
5.56The Australian College of Midwives said that while the establishment of reproductive health leave, including menstrual leave, IVF leave and menopause leave was an 'emerging approach 'for some employers, for many it still remained a taboo subject.
5.57It recommended the creation of formal reproductive health leave policies to better accommodate female workers to take care of their reproductive health, without being penalised by the need to use up personal leave or resort to unpaid leave.
5.58The QNMU also outlined its view that the establishment of formal reproductive health leave and wellbeing policies for employees would enable female workers to take leave associated with menstruation, menopause, endometriosis, pregnancy and fertility treatment, and other reproductive health-related symptoms without being penalised through the use of personal paid leave or the need to take unpaid leave.
5.59The ANMF was of the view that formal reproductive leave policies should allow workers to take a certain number of days leave to cover the discomfort or treatment related to menstruation, menopause, endometriosis, tubal ligation, hysterectomy, pregnancy or IVF. It argued that this would mean women would not be unfairly punished for these conditions by having to deplete their personal leave, and would also bring benefits for workplaces:
Such leave has the potential to improve workplace equality, enhance employee job satisfaction, improve conditions for female employees and achieve greater social and gender equity.
5.60Women's Health in the North asserted that paid reproductive health leave would acknowledge the specific health experiences of people who menstruate and contribute to removing the stigma and taboo surrounding menstruation, menopause and other reproductive health issues. It also made particular reference to the need for leave related to fertility treatments:
Additional paid leave for people undergoing fertility treatment further recognises the medical, emotional and financial toll associated with building a family through assisted reproductive treatment, and supports women and pregnancy-capable people undergoing fertility treatment to participate in the workforce.
5.61Women's Health in the South East (WHISE) recommended that reproductive health leave be legislated in the National Employment Standards as a universal, protected entitlement. Noting that this could be a lengthy process, WHISE suggested that in the interim, the Government should quantify the impact of reproductive health on women's participation in the labour market and conduct public consultation around reproductive health leave to 'establish and socialise community interest and support' for the idea. It cautioned that any action to implement such recommendations needed to be conducted in a way that minimise the risk of reinforcing discriminatory employment practices against women.
Committee view
Sexual and reproductive health literacy
5.62The committee recognises the importance of having high levels of sexual and reproductive health literacy across the Australian population. The committee notes that accurate, inclusive, culturally-safe and age-appropriate sexual and reproductive health information will facilitate better health outcomes across the community.
5.63The Department informed the committee that the Government is currently developing a National Health Literacy Strategy that will consider sexual and reproductive healthcare information. The committee encourages the Department to take into account the evidence received to the inquiry in order to ensure that the National Health Literacy Strategy includes a specific focus on sexual and reproductive health literacy.
5.64The committee considers that comprehensive sexuality and relationships education in schools, if properly done, offers young people a solid foundation to develop lifelong sexual and reproductive health literacy. The committee notes evidence regarding the variability and availability of sex education and health literacy currently taught in schools.
5.65The committee also recognises the need to ensure that all cohorts across the Australian population have access to tailored sexual and reproductive health information. As a result, it encourages the Government to take practical steps in this area to ensure that particular barriers to literacy are overcome.
5.66In particular, the committee considers it important that government jurisdictions and the health sector consider implementation of tailored, culturally-safe strategies, guided and implemented by ACCHOs, that seek to increase sexual and reproductive health literacy amongst First Nation communities.
5.67The committee recommends that the Australian Government work with jurisdictions to improve the quality of sexual health and relationships education in schools including building capabilities of educators to deliver this training.
5.68The committee recommends the Department of Health and Aged Care work with jurisdictions and the health sector to implement options for targeted public awareness and sexual health literacy campaigns in target communities, including for the LGBTIQA+ community, community-led initiatives for First Nations and culturally and linguistically diverse groups, and sexually transmitted infections campaigns in vulnerable cohorts.
Reproductive health leave
5.69The committee is aware that women are disproportionately affected by sexual and reproductive health issues, and that as a result, compared to their male counterparts, female employees typically ended up with less personal leave available for use in other circumstances.
5.70The committee is also mindful that there are many examples of gender-specific health issues that remain unacknowledged or taboo in the workplace, and that this contributes to the challenges working women face in looking after their reproductive health, while also maintaining their workplace earnings.
5.71The committee sees merit in the Government exploring how reproductive leave policies could operate in Australian workplaces. It considers the Government has a role to play in bringing visibility to the conversation in the community about the importance of reproductive health considerations in regard to workplace gender equity.
5.72The committee recommends that the Australian Government considers commissioning research and policy responses on the impact of reproductive health on women's participation in the workforce and the adequacy of existing leave entitlements under the National Employment Standards.
Senator Janet Rice
Chair