August 25th, 2010
The Health Protection Agency has released its most recent figures on Sexually Transmitted Infections (STIs) (including HIV) today. This is based on data collected from GU clinics across the UK annually. You can read the main report here. Those who’re of the more thorough/geekier persuasion may also want to look at the data summaries of STIs (including breakdown by region, ethnicity and age) available at STI Epidemiology in England 2009 and Trends in STI diagnoses. I would recommend reading and critically appraising the HPA report and datasets if you are interested in this topic – particularly if you’re writing about it for the media, blogs or using it in health education/practice.
What are the main findings and recommendations of the HPA report?
* Numbers of new diagnoses of sexually transmitted infections (STIs) in the UK rose by 3% between 2008 and 2009, continuing the trend of the past decade.
* The impact of poor sexual health is greatest in young heterosexual adults and in men who have sex with men.
* There is considerable geographic variation in the distribution of STIs with highest rates seen in urban areas of higher deprivation, reflecting concentrations of the population who are at greatest risk.
* Some antibiotics may become less effective (or even ineffective) in treating STIs in the coming years.
* Increasing sexual behaviour risk may be contributing to the rise in STIs and will have done so in men who have sex with men, but much of the change will have been due to the increasing application of more sensitive tests throughout the past decade and to the more recent expansion of Chlamydia screening of young adults in community settings.
* Prevention efforts, such as greater STI screening coverage and easier access to sexual health services, should be sustained and continue to focus on groups at highest risk.
* Health promotion and education remain the cornerstones of STI and HIV prevention through improving public awareness of STIs and HIV and encouraging safer sexual behaviour such as consistent condom use and reductions in both the numbers and concurrency of sexual partnerships.
Why are UK STI rates rising?
Over the past five years there have been several initiatives to improve testing and treatment for STIs. This has included
- more rapid testing (particularly pee in a pot tests) and screening for STIs such as Chlamydia and Gonorrhea
- greater targeting of the under 25s to have said testing (via GPs, community pharmacies, and GU clinics)
- improved data collection on STI rates via individual services and the Genitourinary Medicine Clinic Activity Dataset
- a shift in focus in public health campaigns from STI prevention and normalising condom messaging towards testing/treatment focus
- attempts to make services more accessible to young people with initiatives such as ‘You’re Welcome’
- sexual health services have been modernising and restructuring, with standards of care established and sexual health networks being created to try and improve sexual and reproductive health services
It would be naïve to claim all of these changes are responsible for the identification of record levels of STIs, nor that all of them have been effective. But it is worth noting (and the HPA report acknowledges) that some of the increased detection of STIs will be down to higher levels of screening. So from that perspective the figures are more positive – it tells us we are identifying and treating people with STIs more than in the past.
Alongside these healthcare initiatives there are other, less positive reasons why STI rates are rising in the under 25s. These include:
Our lack of comprehensive, quality sex education
Sex education remains patchily delivered across the UK with some places doing excellently, others not so well or even teaching negative messages (more information here and here). Young people generally are afraid of unplanned pregnancy (and overestimate rates of unplanned pregnancy), but less aware of STIs. This is particularly the case if education focuses on teaching the names of STIs and showing gory symptoms, but doesn’t explain how you get and prevent STIs or talk about how many are symptomless.
Public Health Campaigns
While we have had government led public health campaigns aimed at the under 25s for the past twenty years these have been patchy, underfunded, and subject to numerous changes in messaging resulting in confusing ideas shared (my insider view of the problems with UK government backed sexual health campaigning can be found here). Despite the limitations of sexual health campaigns from the previous government it is worth noting the current coalition appears to be doing little in the way of public health campaigning for sexual health services.
Access to and funding of services
GU clinics have traditionally been referred to as the ‘Cinderella service’ – not as well funded nor respected as other areas of healthcare. Getting appointments also remains a problem with some services struggling to give appointments in 48 hours or less. In many places waiting times can be weeks rather than days. While demands on services continue to increase, along with the workload of staff rising massively, funding to match these demands is not forthcoming. Perhaps unsurprisingly some staff aren’t always sympathetic which can be off putting. Meanwhile despite underfunding, over expectation and cuts, it is generally staff who are blamed if services don’t hit targets.
Aside from getting seen within services is the wider problem of people knowing how to find them. Many clinics still struggle with promoting their services to the public, or being open at accessible times.
To see how it works in practice, try this experiment. Imagine you’re 16 (or thereabouts). You still live at home. You need to find where a sexual or reproductive health clinic is in your area. Your school hasn’t provided you with any advice, you can’t ask your parents and your friends aren’t much help. Without using the internet, how do you find a clinic locally? Look around your neighbourhood. Can you spot any posters or leaflets? Is there information at your pharmacy or GP practice or library? Are there any youth centres or clinics offering support – and if so when are they open? If you find services are there any that are open at times you could get to? (To make it more challenging imagine you were under confident, struggled with literacy or language, or perhaps had very strict parents who needed to know your whereabouts – this may further limit what you would be able to access).
While there is plenty of research on sexual health services and initiatives to improve waiting times, accessibility, youth friendliness and treatment/testing options, alongside evaluations of what works within sex education, we sadly do not see much in the way of collaborative working. This is often referred to as ‘silo working’ where individual practices, organisations or individuals may well have great ideas but do not share them together. Alternatively work may be replicated (including mistakes) or opportunities for collaborative practice are missed. While services are overstretched, underfunded and pressurised it is difficult to find the time or enthusiasm to network.
Culture, attitudes and sexual climates
Norms and values relating to sexual behaviour have undoubtedly shifted over the past few decades. Pre and extra marital sex is no longer viewed as taboo by the majority of the UK population. Contraception to prevent pregnancy has enabled people to have sex for pleasure. Discussions about sex within popular culture have become more prevalent and some may argue more explicit, although this has not been matched with education to enable people to negotiate a culture that may well feel more sexualised to some. New technologies, the internet and shifts within publishing have allowed easier access to sexual imagery. These are not in themselves a problem but may become one if people do not have the life skills to interpret what they see and enjoy respectful relationships.
Our media undoubtedly plays a role here by covering sexual health stories with a mix of salacious scandal mongering and moral judgement. Every time sexual health data is released the media’s approach is to hysterically report a crisis and speculate on the reasons for it, but at no point to campaign for any initiatives to improve sexual health. The media COULD help by being supportive about sex education, campaigning for more funds to GU services, highlighting how to access services (for local news) or providing accurate sex advice to help people negotiate pleasurable safer sex.
Confusing/mixed messages on safer sex
STI rates can be reduced by condom use. Many young people do use condoms, but they may not consistently use condoms with partners over time. And they may also not get screened for STIs before using a non barrier method of contraception. The focus on testing and treatment without including prevention messages means some young people assume regular testing is sufficient to cope with STIs. Clinicians and sex educators often give mixed messages with some suggesting regular testing is mandatory, others advocating self management and using barrier methods of contraception is better. So people can be confused about what the right approach to managing their sexual health should be.
Confidence and communication
Evidence suggests young women in heterosexual relationships find it difficult to negotiate condom use, while young men will use condoms but won’t necessarily mention them unless a girl does (for more on condom negotiating styles and gender see, for example here). Varying sexual health initiatives have attempted to encourage girls to carry condoms and insist on their use or enable young men to do the same. Some have also focused on clearer communication and negotiation skills both about safer sex but also around discussing other intimate and pleasurable topics together. Studies on men who have sex with men indicate older men tend to be more aware of condom use but there is still variable use within relationships and condoms tend to be used more for anal sex than during other activities like oral sex or masturbation. Both straight and gay couples can assume condoms only need to go on just before a man is going to ejaculate so have penetrative vaginal or anal sex without a condom, putting one on before a guy comes.
‘Risk’ and ‘responsibility’
Negotiating safer sex is more difficult when alcohol is involved, and most people do not assume their partner is likely to have an STI. When you’re thinking about how much you fancy someone you’re not necessarily considering their sexual history. There can also be the view that STIs are things that happen to dirty, bad or promiscuous people – other people, not you. Sexual health messaging – particularly through education and public health campaigns often overemphasise morality discourses of ‘risk’ or ‘responsibility’. These tend to be ineffective as many young people do not consider being intimate as inherently risky or irresponsible. Such an approach also assumes older adults act in different (and more ‘appropriate’) ways than younger people, which is neither fair nor true. Within much sex education and healthcare lies the subtext that ‘good’ sexual behaviour is always being prepared, always having condoms to hand and always effectively negotiating their correct use, while sober. What may be great in theory often simply does not happen in real life.
How did the media (and public) respond to this story?
The media response to this story was interesting. Most coverage I saw repeated the HPA’s press release pretty much, some adding additional comment about why STI rates were so bad (most of them missing key areas as outlined above). While the coverage was perhaps not as hysterical as recent discussions on young people and contraception or abortion, there was still very much a subtext of blame and judgement among much coverage. Accompanied by a lot of handwringing about the state of our nation’s sexual health with relatively little discussion of what we might do to improve our wellbeing.
The overwhelming majority of coverage did not clarify that much of the increased prevalence in STIs was down to testing initiatives and treatment programmes. The focus suggested the STI rates were solely down to young people having multiple partners.
It seemed most journalists did not consult the HPA report nor particularly interrogate the data. Those called upon to comment were not generally selected from GU services or sexual health research. Instead it seemed anyone who’d ever written something about sex, sex therapists or generalists on the topic were asked to give their opinion about young people and their behaviour rather than appraise or expand upon the HPA data. Some of the comments made by sex experts on twitter, broadcast and print media clearly showed they had also not consulted the HPA report but still commented on its findings. It is very worrying when both a journalist and the person they ask to explain a report have not actually looked at said data.
Additional input from experts and the public shifted the debate towards a more blame-focused narrative generally blaming young people, or repeating memes such as:
- young women are all victims, they cannot make decisions for themselves
- young men are all predators, who are at the mercy of their overactive sex drives
- feminism has caused young women to act like men
- Sex and the City has taught young women to be promiscuous
- Young men are being blamed for STI rates
- Young women are being blamed for STI rates
- Young men’s needs are being ignored
- Young women’s needs are being ignored
- Young people are feckless, irresponsible and simply don’t care about STIs
- ALL young people undoubtedly know ALL about STIs and cannot claim otherwise
- Sex education/pornography/rap music etc is to blame for rising STI rates
- STIs were not a problem for previous generations
- Scaring young people about STIs will put them off having sex and combat this trend
- Young people who get STIs (particularly repeatedly) should be punished/refused access to healthcare
- STI rates are just as bad in the over 40s, if not worse than in the under 25s
While some of these are more extreme than others it does show how often this debate is further hampered by moral and opinion based discussions that have very little to do with the realities of why young people get STIs. Rather than exploring reasons and finding solutions we are encouraged instead to blame, shame and generally judge people who have STIs – not focus on wider causes or feasible solutions.
What can we do about our STI problem?
This is not a case of us having a problem but not knowing what to do about it. Our epidemiological data for STI rates is improving every year, sexual health services are modernising and new initiatives for testing/treatment are available, alongside prevention messages and strategies to promote safer sex. We know quality sex education increases safer sex and the likelihood of people being able to communicate their sexual needs assertively while reducing coercive behaviour. We know that training up teachers and health professionals to talk about sexual health issues with confidence – and to see these issues as important is necessary. We know young people are interested in such information. We know services would work better with more funds and resources, and if collaborative working was encouraged – and if the media supported rather than scuppered sexual health initiatives.
There is no mystery here. We have ample evidence to fix this. We are failing to do so because our debates on this issue focus on blaming young people and those with STIs and not focusing on the systemic problems that need to be fixed. This is not to say people are not responsible for their own sexual health, but with our current haphazard approach we also do not enable people to take control over their sexual wellbeing.
Data like this always tells a story – about people affected by STIs. But it perhaps masks the discomfort, anxiety, nuisance, distress or fear having an STI may cause. It misses what can happen to relationships, people’s self esteem, or future fertility.
It’s very easy to sit in judgement on those who have STIs. Assuming you don’t have one (are you sure?) or you would never have unprotected sex. It is very easy to believe we’re facing rising STIs purely because of feckless youth. But it completely misses the point. This is a major health crisis – and it affects us all.
Sources of help, advice and further resources
Sexual Health Helpline call 0800 567 123
NHS Choices on Sexual Health includes resources, advice materials and the facility to find your nearest sexual health/genito urinary clinic by postcode
Manchester Sexual Health Network has created the most comprehensive list of related links on GU/SRH I’ve found
NHS Evidence – Sexual Health Services links to resources, data and research on sexual health in the UK