Sexual Health Ill

Factors that contribute to the poor sexual health of Britain’s youth

Introduction

Problems with sexual health affect all sections of society including all age groups. Sexual ill health disproportionately affects vulnerable groups such as young people between the ages of 16 and 25, ethnic minority groups and those affected by poverty and social exclusion. (World Health Organization, 2004) Sexual health refers to the issues which impact on sexual function and reproduction. Such issues include a physical, mental and emotional factors which may have a varying amount of impact on the individual, leading to disorders affecting physical, mental or emotional wellbeing. (Dehne & Riedner, 2005; World Health Organization, 2004)

Sexual ill-health may thus be defined as the consequence of such issues in terms of their effect(s) on the wellbeing of an individual. Serious complications with sexual health particularly affect women and gay men and there are disproportionate geographical inequalities in the rate and degree of sexual ill health and inequalities in sexual health service provision in the UK. For example, the results of a study focusing on syphilis reported that there have been increasingly high rates of disease transmission over the last five years in Britain, as well as in several parts of Western Europe. The report also stated that the most alarmingly high rates of syphilis prevalence have been seen in the wealthiest cities of England such as London. (NHS, 2008)

According to the Independent Advisory Group on Sexual Health and HIV, (2007) there are serious inequalities in sexual health service provision in the UK and the groups most likely to suffer because of this are identified as young people who are considering becoming sexually active, men who have sex with men and black and minority communities. The possible reasons for such inequalities are discussed further in detail, along with the importance of these issues being reprimanded and their effects reduced. The major causes of morbidity and mortality among young people are road traffic accidents, suicide, drug use (including cigarettes, cigars and alcohol) and sexual and reproductive ill health. (World Health Organization, 2004) The consequences of poor sexual health have important implications for all individuals as well as society as a whole.

Unwanted pregnancies may have a long lasting impact on quality of both the mother’s and the child’s life. Since the International Conference on Population and Development in Cairo in 1994, recognition of young people’s specific sexual and reproductive health needs has gradually increased. Attempts to date to promote the sexual health of young people have tended to focus on prevention, education and counseling for those who are not yet sexually active, while the provision of health services to those who have already engaged in unprotected sexual activity and faced the consequences, including pregnancy, STIs or sexual violence has lagged behind. (Dehne & Riedner, 2005)

The identification of this matter has lead to a shift in focus on sexual health and motivation towards the promotion of services available to people in the UK. In 2004, the World Health Organization (WHO) launched an activity to promote sexual health and a positive view of sexuality for young women and men as issues to be addressed separately from the wider subject of reproductive health. In the past, but particularly since the 1994 International Conference on Population and Development, sexual health was defined as an incorporation of the subject of reproductive health. The launch of this activity was the direct result of the emergence of the pandemic of human immunodeficiency virus (HIV) infection, increasing rates of sexually transmitted infections (STIs) and an increasing awareness of the importance of gender-related violence and sexual dysfunction concerns. Such changes in sexual health have emphasized the need for more explicit focus on issues related to sexuality and the direct implications for general health and wellbeing. (World Health Organization, 2004)

Despite efforts made to strategize improvements to sexual health policies in recent years, data shows that numbers of STIs in Britain continue to grow at a problematic rate and cost the National Health Service dearly in prevention and treatment methods. Statistics regarding sexual health in Wales published in Better Health – Better Wales in 1998 (Welsh Office, 1998a) highlighted trepidation regarding the high rates of teenage pregnancies and STIs in the region. In response to these concerns, the Welsh Assembly’s publication Better Health – Better Wales Strategic Framework (Welsh Office, 1998b) included a commitment to the people for the betterment of sexual health and to take account of and successfully deal with the inequalities surrounding sexual health concerns.

Strategies were also directed towards the improvement of emotional support for those involved in sexual relationships, as well as support for the education of sex in schools. In addition to the responsibility assumed by England and Wales to try to tackle sexual health concerns, Scotland also released a response to growing rates of abortions, unwanted pregnancies and ill health in the form of a Sexual Health and Relationships Strategy, (Scottish Executive, 2005) which aimed to challenge the government for better services by promoting a strategy based firmly on “self-respect, respect for others and strong relationships” (Scottish Executive, 2005). In short, action was directed towards the avoidance of contracting and spreading sexually transmitted infections and towards the avoidance of unwanted pregnancies by promoting the individual’s responsibility for themselves and others through specific educative measures.

Despite the efforts made by the three governing bodies in the UK to act on sexual health concerns, there is evidence indicating that some years on, we are still seeing problematic levels of unwanted pregnancies and sexually transmitted infections in young people and a systematic review of the literature seems to suggest limited knowledge of sexual health associated with young people. (Wellings et al., 2002; NHS 2007)

A thorough study of the literature concerning sexual health in young people reveals that there are four main areas of consideration for this matter. These include the level of knowledge of sexual health to young people, consequences of sexual ill health, factors influencing the use and non-use of condoms and intervention(s) for the promotion of condom use. We therefore now take a closer look at the condition of sexual health in young people in the UK in detail to identify the specific areas where intervention can promote better sexual health in order to reduce the prevalence of sexually transmitted infections in this group of people and we also give further consideration to the consequences of STIs and the factors affecting the use of condoms.

According to a study performed in 2001, when compared with several countries, Britain has a relatively low rate of HIV and other sexually transmitted infections, which reflects the historical investment in establishing the Genito-urinary Medicine (GUM) clinic. However, data from 2001 showed evidence that there is heterogeneity in the population distribution of STIs which are diagnosed, and the wide distribution of undiagnosed Chlamydia showed that the strategy adopted in Britain in response to the International Conference on Population and Development in 1994 failed to relieve the problem of ill sexual health by 2001. (Fenton et al., 2001) Looking a little later on to over a decade since the international conference, we learn that the number of newly diagnosed sexually transmitted infections continued to rise in 2006 indicating that sexual health still required careful attention at this time. Furthermore, the same study showing that sexually transmitted infections were still on the rise in 2006 also gave overwhelming evidence that the highest rate of STI diagnoses continued to be among young people between the age of 16 and 24 years and that genital herpes in particular sharply rose by 16% from 2005 to 2006 in teenage women. (Hughes et al., 2006)

There is much further evidence in the literature to show that young people are most at risk from sexual health problems including notable statistics which show that Chlamydia affects one in ten sexually active young women and each year, numbers of cases rise by 9%. (Department of Health, 2003) There is thus, some significant evidence showing that sexual health in the UK continues to decline and any efforts being made to prevent such an increase in rate of infection are clearly neither sufficient nor effective. This effect on young women has changed little since 2003 and remains a cause for concern at the present time. (Department of Health, 2003; IAG, 2006/2007) Recognition of the problematic numbers of affected young people, particularly women lead to the implementation of a strategy designed to tackle ways of reducing teenage pregnancy and improving sexual health among vulnerable groups of young people.

This strategy ended in December 2006, yet there still remains concern regarding the health of young sexually active people supported by statistics documenting the behaviour of young people today. Sexually transmitted infections (STIs) among adolescents in particular, are of great concern to all those who work to improve the health status of human populations. Sexually transmitted infections are widely associated with stigmatization, denial and embarrassment among patients and health workers. Sexuality and associated health risks are still a major taboo in many societies and this may be especially true for young people between the ages of 16 and 25 years. While the young person’s rights and needs may be acknowledged in theory, the story is very different in practice and they are still confronted with many barriers when it comes to obtaining the practical support they need to avoid health concerns. According to Dehne and Riedner (2005) an indication of their “unmet needs” is the worldwide scarcity of services available for young people, in particular, services related to the treatment of sexually transmitted infections. (Dehne & Riedner, 2005)

Significant data has shown that almost 30% of young men and nearly 26% of young women report having sexual intercourse before the age of 16 and by the age of 20, the majority of young people have had sex. (Brook, 2001) The high number of young people having sex at an early age means that this group has a high risk of transmitting sexually transmitted infections and indeed of becoming unintentionally pregnant. Evidence supporting this is found in a study by Marston and King (2006), who found that nearly 50% of new HIV infections worldwide are found in young people between the age of 15 and 24 years.

Further evidence suggests that this figure is nearer 60%. (Dehne & Riedner, 2001) Thus there is some significant room for attention towards this group to change sexual behaviour to deal with a pandemic such as this. (Marston & King, 2006) The high risk of STI transmission, as well as the increased chance of encountering other sexual health problems in young people has led to the motivation for this study and we are persuaded that there are inextricable forces acting on young people, which are causing them to suffer unnecessarily. We offer a thorough investigation into the causes of various sexually transmitted infections and ill-health epidemics in the UK in the hope of identifying the main voids in bureaucratic procedure towards the paradox of sexual health in young people.

Research on sexual health in young people seems to suggest that knowledge of the causes and consequences of sexually transmitted infections as well as the consequences of sex in general to young people maybe limited (Wellings et al., 2001; NHS, 2007) and it is likely that this lack of knowledge is a large contributing factor in the high prevalence of STIs in young people in the UK. The fact that ‘young’ signifies only very few years of experience as a sexually mature adult is also, albeit an obvious one, a reason for the high parameters of sexual health problems in this group of people and another why they might have unsafe sex.

Although sexual education begins at a young age (usually 11 years old and lasts until 16 years), a report by Lester Coleman (2007) on the preferences towards sexual education by a multi-cultural group of individuals revealed that despite the different religions of children in schools in Britain today, there are a number of similarities across practising religious groups which include the preference for more information regarding STIs and how to increase sex satisfaction. Thus, there is evidence to suggest that there is at least some room here for improvement in the educational methods used for the prevention of sexual health problems through knowledge acquirement. (Coleman, 2007) Furthermore, according to Jackson and Plant (1997), despite the improvement in the knowledge of sexual health matters to young people shown in the early 1990s, young people lack knowledge about how to use sexual health services provided and they are also unsure about the issue confidentiality to their parents and general practitioners if they were to attend a surgery or family planning clinic for advice and/or treatment.

This revealing might help to explain not only the high numbers of STIs and unwanted pregnancies in young people, but also the lack of knowledge young people have of matters relating to sexual health. Also, the failure of most young people to recall the anonymity of sexual health services, as found by Jackson and Plant (1997), clearly shows the lack of communication between educators and students over these matters, or perhaps more accurately, the failures of sexual health educators to effectively inform young people of all of the important elements relating to advice and treatment of sexual health problems. If proper communication was involved between informer and ‘informee’ and feedback was necessitated, it should have been obvious that anonymity would be a major concern to young people requiring treatment or advise, especially those who are below the legal age to be having sex, or indeed those with cultural backgrounds who do not allow sexual activity at their current age.

Campaigns over the recent years targeting young people have encouraged safe sex through promoting condom use and the avoidance of penetration. Efforts have included dispensing free condoms and providing information through schools. However, even in instances where condoms have been widely available and education of sexual health problems has been great, such campaigns have not been desirably successful. It has been demonstrated that there are powerful cultural and social forces in play, which appear to strongly influence sexual behaviour. This discovery might help to explain why free dispensation of condoms is not working as well as expected to reduce rates of sexually transmitted infections and unwanted pregnancies. It might also help to explain why some of the HIV programmes have also not been effective. (Coleman, 2007)

Consequences of sexual ill health

The physical symptoms of sexually transmitted infections are varied but there are a few generalizations which include itching, redness and soreness around male and female genital parts. The most common STI to date is Chlamydia, which is caused by the bacterium Chlamydia trachomatis. In women the infection often presents no symptoms which makes diagnosis without examination difficult in many cases and there may also be non-specific symptoms such as cystitis, an altered vaginal discharge or abdominal pain. If left untreated, the female reproductive organs can be irreparably damaged and can cause sterility. (Centre for Disease Control and Prevention, 2007)

Men may experience pain whilst urinating, develop a discharge from their penis and have inflammation of the urethra or testes. (NHS, 2007) Other sexually transmitted diseases which are common effects of unprotected sex and which have various physical symptoms leading to damage of the reproductive tract if left untreated are: genital warts; genital herpes; gonorrhoea; syphilis; HIV; trichomoniasis; pubic lice; scabies; thrush; and non-specific urethritis. Emotionally, the occurrence of an STI can cause problems for the patient related to a feeling of shame and of being ‘dirty’, especially in the event that a patient must make contact with previous partners to inform them of their infection. (NHS, 2007)

There has been an increase in the interest in the sexual behaviour of young people in the second half of the 20^th century, which has been fuelled partly by a concern for their sexual wellbeing. In the 1960s and 1970s, nervousness surrounding the rates of contraception among young unmarried people provided the impetus to much research, but a decade later, the focus shifted to the risk of HIV transmission among young people. By the end of the 20^th century, the UK had the highest rate of teenage births in Western Europe and an increasing rate of most sexually transmitted infections among young people. Attention has now focused on risk behaviour in the context of both sexually transmitted infections and unplanned pregnancies in young people. (Wellings et al., 2001) and it is estimated that the prevention of unintended pregnancies saves the NHS over £2.5bn a year (Kinghorn, 2001; The Department of Health, 2006).

The average cost of contraception failure is estimated at £1500 per person, which is inclusive of the costs of abortion, miscarriage, ectopic and live births. (Department of Health, 2006) Sexually transmitted infections (STIs) are associated with serious maternal and neonatal morbidity, infertility, anogenital cancer and transmission of human immunodeficiency virus (HIV). The average lifetime treatment cost for each HIV positive individual was estimated to be between £195,000 and £200,000 (Bernard, 2006; Bartlett, 2007).

At £580 million a year, HIV imposes a significant burden on healthcare resources. As well as the high cost of care and treatment, HIV is associated with extreme morbidity, significant mortality and a significantly reduced life. It has been determined that preventing the onward infection of just one case of HIV saves the NHS around £0.5 million in health care costs and individual health gains. Figures at the end of 2006 indicated that the direct costs of treating other STIs cost the health service approximately £165 million a year and if the cost of treating sequelae were to be included, this would increase exponentially.

Chlamydia, for example, often produces no symptoms, but if left untreated it can lead to pelvic inflammatory disease, infertility and ectopic pregnancy, which impose high costs on individuals and on the National Health Service. (The Department of Health, 2006) When fertility treatment such as in vitro fertilization (IVF) becomes necessary due to fertility problems associated with STIs, there is no funding available for patients and those people affected much shell out thousands of pounds for such procedures. The NHS offers no help for any person requiring fertility treatment, despite evidence seeming to point to the failure of government bodies responsible for the promotion of sexual health to effectively diagnose and treat people with sexual health issues. (NHS, 2007)

Gender is an important issue in STI prevention and care and there are many scientists who believe that gender is the largest role being played in the prevailing increase in sexually transmitted infection rates. (Marston and King, 2006; Coleman, 2007) Gender-based inequalities put girls and young women at an increased risk of becoming infected with a sexually transmitted infection and these inequalities also affect these women’s access to prevention and care services.

In addressing these inequalities, we must try to best consider the different requirements and also constraints of young women and young men when we are designing interventions to tackle sexual ill health. (Marston and King, 2006)

According to a study by Marston and King (2006), sexual partners influence the behaviour of young individuals in many ways and young people are known to assess potential sexual partners as “clean” or “unclean”. Furthermore, there appears to be certain stigmas associated with condoms, such as a lack of trust, and societal norms prevent the lucid communication about sex. (Marston and King, 2006) From a biological perspective, hormonal changes in young men and women which are likely at various times between the age of 16 and 25 years will have a profound affect on the decision-making ability of the individual; especially in younger years and this is likely to be a plausible explanation for certain acts considered by individuals as ‘mistakes’. (Verhoeven, 2003)

STIs such as chlamydia, syphilis and gonorrhoea are passed from one individual to another through intimate sexual contact either during vaginal, anal or oral intercourse with an infected partner. (NHS, 2007) The timing and conditions of sexual initiation are of substantial interest in the context of public health. Early age at first intercourse is associated with subsequent sexual health status. Following the steep decrease of age at first intercourse among women up to and incuding the 1970s, in many countries there is evidence of subsequent stabilisation. In several European countries, this stabilisation occurred in the 1980s. In Britain however, heterosexual intercourse continued to occur at earlier stages throughout the 1980s. Factors associated with early age at first intercourse are well documented and include early school leaving age, early menarche, family disruption and a disadvantaged and poor education. A study by Wellings et al., reported a decline in age at first intercourse in successive age-groups and significant increase in condom use among the youngest age cohort, born between 1971 and 1976.

Several important trends have been identified in this data from the National Survey of Sexual Attitudes and Lifestyles (Natsal) in 2000. There seems to have been a stabilisation of the proportion of people having first heterosexual intercourse before the age of 16 years among women, as well as a continuation of the increase in condom use and in the decrease in the proportion not using contraceptive methods at first intercourse. There also has been identified an increase in the importance of school in the sexual education of the young, in particular men.

Despite the strong trends identified in this data, the author is right to point out that the data is based on alleged behaviour and thus is susceptible to biases associated with recall and veracity. With time, it is pointed out, early experiences may be recast or forgotten although the ability to recall any event is dependent on the time passed since the event’s occurrence, and also on its salience. According to the results of experiments, less than 1% of respondents were unable to remember, with accuracy, their age at first intercourse. This result demonstrates that first intercourse is fairly non-memorable for individuals and there may be implications here into the general lack of responsibility taken with regards to contraception at this time.

Further, if we look at the decade of the 1990s as a whole, a higher proportion of young women in Britain reported heterosexual intercourse before the age of 16 years when compared with the previous decade and the median age at first intercourse was also shown to be lower for men than women. Looking within the 1990s however, there are some tentative and possibly ambiguous signs in the data that the trend showing increasingly earlier heterosexual intercourse may have in fact stabilised for women.

Furthermore, there is evidence of increasing adoption of risk reduction practices. For only a minority of young people is first intercourse unprotected against infection and conception. The data in the study shows a remarkable rise in condom use in Britain, despite the predictions that a weaker impact of AIDS-linked safer sex messages might have brought about complacency. 25% of young women in this study were already using oral contraception at first intercourse but with respect to the circumstances of first intercourse, the evidence is less positive. Despite the agreement in the behaviour of men and women at particular ages at which first intercourse occurs, there remain gender differences in the experience of the event such as those described above. The proportion of those young people who are sexually proficient according to the criteria which was used, has increased over time; particularly among men. Further evidence reveals that women are two times as likely as men to regret their first experience of intercourse and three times as likely to report being the less willing partner. These findings have also been supported by Wight et al., 2000 and Dickenson et al., 1998.

26% of women aged between 16 and 19 in this study were found to have had intercourse by 16 years, which is the legal age to have sex in the UK. (NHS, 2007) There is evidence to suggest that a focus on absolute age at first intercourse may not take into account variations in individual development and social norms. Although sexual competence decreases substantially with age at intercourse, more than 30% of young women for whom first intercourse occurred at age 15 years were sexually competent, and more than a 30% of those aged between18 and 24 years at the time were not.

The report shows early age first intercourse to be significantly associated with early pregnancy but not experience of sexually transmitted infection. Although early menarche is independently associated with early age first intercourse and with early motherhood, importantly, in terms of the potential for enhancing sexual health, the risk behaviours and outcomes described are also associated with cultural and social factors.

Of these, the association is stronger for education than for family background. Young people who leave school later, with qualifications, are less likely to have early intercourse, more likely to use contraception at first sex, be sexually competent and, for women, less likely to become pregnant if they have sex. Family disruption and lower parental socioeconomic status are also associated with early sexual experience and pregnancy when younger than 18 years, but the effect is weaker. (Wellings et al., 2001)

The absence of a significant association between educational level and abortion, compared with the strong association with motherhood at younger than 18 years, supports the premise that educational prospects influence the outcome of pregnancy. We do not know to what extent poor educational aspirations themselves lead to early sexual experience and motherhood and the extent to which having a child early in life thwarts academic expectations. Nevertheless, this data identifies a vulnerable group of women in public health terms; 29% of sexually active young women in this study who left school at 16 years with no qualifications had a child at age 17 or younger.

From the viewpoint of prevention, there is much that is positive in this data: the sustained increase in risk reduction at early sexual experience; the increasing prominence of the school in the sexual education of the young and the fact that the variables which emerge as most strongly associated with reducing risk are those which are amenable to intervention. Of interest too, with respect to the possible stabilisation of the trend towards intercourse is the evidence from the USA of a reduction in the teenage pregnancy rate following their earlier experience of a similar trend. The strong association between educational attainment and early motherhood also supports the British government’s strategy to marshal the efforts of ministries concerned not only with health but also with education and social services, in a bid to reduce the incidence and adverse outcomes of early teenage pregnancy.

Marston and King, in their 2006 study found that there are penalties and rewards encountered for sex which may well affect the rate of STI transmission in the UK. According to these two authors, social rewards and penalties influence sexual behaviour. Adhering to gender expectations and formalities has been seen to raise social status. For women, complying with stereotypes can secure an exclusive relationship with a man, and for men, complying can lead to many partners. (Nyanzi et al., 2001)

While pregnancy outside marriage can be stigmatising, for some women pregnancy can be a way out of the parental home. Young people may behave in particular ways through fear of being caught in the act. Sex can also be a way to obtain money and gifts from boyfriends:, which is particularly well described for sub-Saharan Africans, although this behaviour is not exclusive to this part of the world. (Nyanzu et al., 2001) It is believed that the relationship between individual enthusiasm and societal expectations is a complex one as some behaviour considered taboo can become desirable for that very reason. (Marston and King, 2006)

Reputations are crucial for social control of sexual behaviour according to scientists. Marston and King, 2006; Stephenson et al., 1993) Reputations are linked to displays of chastity for women, or heterosexual activity for men. Social isolation can result from activity leading to being branded “queer” or a “slut”, and in some cases, such brands can result in worse cases such as gang rape and murder. (Wood et al., 1998) A woman’s reputation can be damaged by having “many”, or more than one partners according to Marston and King (2006) and even the mentioning of sex can risk implying sexual experience and lead to a damaged reputation.

Although it has been found that communication across generations about sex is rare, family members may for instance prevent young people socialising with members of the opposite sex to protect the reputation o the family. (Hennick et al., 1992) Young men’s reputations can suffer if they are not seen to push for sexual access and numerous female partners according to some scientists, (Varga, 1997; Harrision et al., 2001) thus, the display of heterosexual activity can be important. It is common that some groups of men visit brothels together in Southeast Asia and young men proudly report sexual experiences to their peers. (Varga, 1997) Furthermore, there is often a stigma attached to not having penetrative sex, and indeed not being able to do so. Young men not having sex with their girlfriends may be accused of being “gay”.

According to a study in Britain by Hughes et al., (2007) new STI diagnoses increased between 2005 and 2006 by an overall 2% whilst diagnoses of other STIs increased by 3% over the year. Looking further back, there has been an increase in new STI diagnoses of 63% between 1997 and 2006 and an 84% increase of existing STIs over the same time period. According to these figures, strategies in place between these times were not working effectively to reduce the incidence of STIs in young people.

Between 2005 and 2006, services available to the public in the form of clinics and sexual health screening and HIV tests were increased by 6% thus making them more readily available. The number of HIV tests taken was said to have risen by 12% over that year and the number of sexual health screens rose by 9%. (Hughes et al., 2007) Thus, despite the increase in the services available to the public in the early 2000s, STI incidence continued to rise. There is therefore clearly a huge requirement for the betterment of these services to allow a significant reduction in new and existing STI diagnosis.

Presently, services available to young people with sexual health concerns include genitourinary medicine (GUM) clinics, which are usually situated in separate Primary Care Trust departments at hospitals around the country. The NHS also provides a numbe