APPENDIX 49
Evidence submitted by fpa (formerly the
Family Planning Association) (PH 92)
SEXUAL HEALTH
INTRODUCTION
Sexual health is a key public health issue.
In the twentieth century the great innovations in sexual health
including:
— universal free contraception;
— open access specialist services to
treat STIs; and
Took their place alongside other major public
policy measures which promoted public health. It is easy to forget
that in the 1960s illegal abortion was widespread, with many women
being admitted to hospital after unsafe operations, and that a
number of these women died. For the hundreds of women unable to
obtain contraception, the fear of unwanted pregnancy dominated
their lives and inhibited their relationships. Today major public
health issues still confront the UK, including the impact of HIV
and AIDS, high levels of teenage pregnancy and the increasing
level of Chlamydia infection, which all too often brings with
it the misery of pelvic inflammatory disease, ectopic pregnancy
and infertility.
Yet sexual health is frequently seen as a private
or life-style issue rather than being a mainstream public health
issue. In our modern pluralist society, the life-style approach
to sexual health recognises that:
— it is unacceptable for any one section
of society to impose their values on others;
— sexual health can only be achieved
if people are able to make informed choices; and
— appropriate services are available
to support them in so doing.
However, the ability to make an informed choice
and to access services is affected by behavioural, emotional,
social, economic and political factors, making sexual health a
very significant aspect of public health as a whole.
Achieving and sustaining individual sexual health
requires high levels of emotional intelligence defined as "the
ability to recognise and name feelings as we experience them,
and to acknowledge the impact they have on our actions and on
others". Emotional intelligence is central to the public
health imperative of strengthening individuals and strengthening
communities. It is fundamental to strategies to counter inequalities
and social exclusion. Sexual health is vital for good relationships,
and good relationships provide a basis for confident engagement
with community, civic and social life.
THE STATE
OF SEXUAL
HEALTH IN
THE UK
Sexual health, the capacity and freedom to enjoy
and express sexuality without exploitation, oppression, physical
and emotional harm, is central to every individual's physical
and mental well being. There is a wealth of qualitative and quantitative
evidence which shows that sexual health in the UK is poor.
The capacity and freedom to enjoy and express
sexuality requires a social climate in which it is possible to
be open about sex. Such a climate does not exist in the UK. While
the situation has improved since the first HIV awareness campaigns,
many aspects of sex and sexual health are still affected by taboos.
Examples abound and include the negative publicity surrounding
the abolition of Section 28 (in England and Wales) and Section
2a (in Scotland) and the coverage of the licensing of hormonal
progestrogen emergency contraception for pharmacy provision.
In addition, overall indicators of sexual health
show a very worrying position:
— the UK has the highest rate of teenage
pregnancy in Western Europe;
— approximately one fifth of all pregnancies
ends in abortion;
— a sixth of couples seek assistance
for infertility;
— the number of new HIV infections
in the UK increased by 6 per cent between 1998 and 1999;
— there were nearly 590,000 new cases
of STIs diagnosed in GUM clinics in the UK in 1998—an overall
increase of 6 per cent; and
— chlamydial infection in the UK is
increasing rapidly, especially amongst young women.
Sexual health is both a human and a social right
which is essential to the exercise of full citizenship. It is
also the basis for enhancing individual and community health and
well-being through the promotion of the healing and creative power
of sexuality. These figures demonstrate the current deficit in
sexual health and the urgent need for action.
INEQUALITIES
There is currently a lack of data to build a
comprehensive picture of the range of inequalities in sexual health.
However, there are significant examples of inequality. For example,
the relationship between teenage pregnancy and low socio-economic
status and low educational achievement is well documented and
illustrates the disadvantaged position of groups of young women.
The needs of boys and men are also not adequately recognised so
they are not met by sexual health services.
There is a particular stigma attached to aspects
of sexual health, for example HIV, other sexual transmitted infections
and abortion, and to certain groups especially vulnerable to sexual
ill-health. This stigma brings an added dimension to inequality.
Homophobia is a major contributor to the inequality
experienced by gay men and women, whose sexual health is often
affected by oppression or physical or emotional harm. They have
difficulty accessing appropriate sexual health advice from both
primary care and specialist providers. Generic health promotion
does not meet their needs and leaves them vulnerable to poor sexual
health.
CURRENT SERVICE
PROVISION
Currently, sexual health services are fragmented
and of variable quality. Few arrangements are based on a systematic
needs assessment. Access is often limited through either insufficient
provision or restrictive policies. The main issues at local level
in each of the major areas of provision are:
Contraceptive advice
In Britain, the majority of consultations about
contraception take place in General Practice. GPs receive an additional
fee for providing this advice to women, but not to men, regardless
of their knowledge or training. Many GPs do not offer the thirteen
different methods of contraception but concentrate on providing
hormonal methods. GPs are not usually funded to provide free condoms
to prevent pregnancy and reduce sexually transmitted infections.
There are a number of high quality nurse led
clinics yet, in general, nurses are underused in the provision
of contraceptive advice. Extending the power to prescribe to appropriately
trained nurses has been discussed for 20 years but the necessary
legislation has yet to be put in place.
Ignorance about the full range of methods is
widespread, not only among members of the public but also among
primary care professionals. As a result, many women are denied
the opportunity to make an informed choice about the method which
would suit them best. Choice is also restricted by budgetary limits
on methods that are initially more expensive. However, research
shows that for every £1 spent on contraceptive services there
is a saving of £11.
For many years it has been Government policy
that women should be able to seek contraceptive advice from a
GP other than their own or from a Community Clinic. However, this
choice is not always available; there are many areas without local
clinics or where access to clinics is limited to younger women.
Emergency Contraception
Awareness of emergency contraception and the
time scale within which it should be used is very high amongst
potential users. However, there are frequently major barriers
to using it, including difficulty in getting a timely appointment
with a GP or other provider and, in some cases, professional ignorance
or prejudice about its use. Whilst the availability of emergency
contraception from pharmacists will increase access for women
who can afford it, the majority of these barriers will still remain.
Abortion
Although abortion has been legal in England,
Scotland and Wales under the terms of the 1967 Abortion Act for
over 30 years, many women still experience major difficulties
in obtaining an NHS abortion. Problems encountered include waiting
times for appointments with their GP, or once referred, with an
abortion provider, the attitude of their GP to abortion in general
or to their particular circumstances and their health authority's
policy towards providing NHS funded abortions. In 1998, the percentage
of NHS funded abortions varied from 95.8 per cent in the best
authority to 44.5 per cent in the worst. It would never be suggested
that a woman should have to seek private maternity care because
she does not meet local criteria for an NHS birth, but this is
frequently the case for abortion.
There is also considerable variation in the
method of abortion provided in the early stages of abortion. Medical
abortion for use up to nine weeks of pregnancy has been available
in this country since 1991. Yet in 1998, the number of medical
abortions as a percentage of all pre-nine weeks abortions varied
from 58 per cent in the Northern and Yorkshire region to 5.4 per
cent in the West Midlands. Furthermore, in some services the rate
is as high as 75 per cent. While not all women wish to have a
medical abortion, it is cheaper and has less risks associated
with it than surgical abortion. Many women are being denied this
option.
Women in Northern Ireland face even greater
barriers than those in the rest of the UK. While some abortions
are carried out in Northern Ireland, the majority of women seeking
abortion have to travel to Britain. As a result, they tend to
have abortions later in pregnancy which means increased risk.
They also face considerable expense and disruption to their lives.
Sexually transmitted infection
Many people seek advice about sexually transmitted
infections in the first instance from their GP. As with contraceptive
advice, GPs vary in their expertise in this area. They are not
required to keep any record of the number of consultations for
sexually transmitted infections, so unlike contraception, information
is not available about the number of these consultations taking
place each year within general practice.
Every health authority area has a self-referral
provision for the diagnosis and treatment of sexually transmitted
infections. However, in many areas pressure on these services
is so great that there are serious delays in obtaining appointments.
Currently, there are pilot schemes in operation
in Portsmouth and the Wirral, where screening for Chlamydia is
being offered to young women in primary care, family planning,
sexual health and antenatal services. The results of these studies
should be published shortly.
Public awareness about Chlamydia and its potential
consequences for women's health is limited although increasing.
However, many women are falsely reassured by the belief that when
they have a cervical smear, they are also being screened for sexually
transmitted infections.
Information
At national level, fpa is funded to provide
the Contraceptive Education Service in England, Scotland and Northern
Ireland. This is a comprehensive service with a helpline and information
service for the public, professionals and the media, information
leaflets on contraceptive services and methods and a specialist
library and information service for professionals. It handles
over 100,000 inquiries a year. As a result, fpa has a unique overview
of sexual health provision as experienced by both the public and
professionals.
Although styled as providing information about
contraception, the service covers all aspects of sexual health
including contraception, conception, infertility, early pregnancy,
abortion, sexually transmitted infections and sex education. During
2000 a directory of all UK clinics which offer sexual health,
including contraceptive advice, has been created on fpa's website.
The service also acts as a gateway to other sources of information
and advice.
The service receives many calls from women who
are uncertain about how they wish to respond to an unintended
pregnancy and who have been unable to locate a service to help
them decide what to do. Currently, the service is not resourced
to respond fully to these calls.
The Contraceptive Education Service has worked
closely with NHS Direct, looking at the relationship between the
specialist and the generalist helpline. We envisage that as the
public's awareness and use of NHS Direct increases, it will deal
with routine enquiries, allowing fpa to focus on those where its
specialist expertise is essential.
National Campaigns
National campaigns have played a significant
role in increasing public awareness of sexual health issues. For
example, there have been a number of campaigns about emergency
contraception and more recently, there has been a focus on chlamydia.
While individual campaigns do not lead to immediate changes in
behaviour, they do provide vital information and increase awareness
without which behaviour change is unlikely.
GOVERNMENT POLICY
Differing views within society about sex and
sexual morality make sexual health a sensitive area for public
policy. The Government should be applauded for legislating to
equalise the age of consent for gay men and for attempting to
repeal Section 28. However, in other key areas, notably abortion,
they have done little. The vociferous anti-choice minority has
powerful allies in sections of the popular press. Without a strong
Government voice in support of women's rights within existing
law, abortion will continue to be marginalised within the NHS.
Many girls and young women develop anti-abortion attitudes without
ever having had the opportunity to consider the issues fully.
As a result, if they have an unintended pregnancy they are unable
to make an informed choice for the future.
The Government is currently developing a Sexual
Health Strategy which will provide the framework for sexual health
services in the future and will, we hope, address the many urgent
matters raised in this paper. A successful Strategy must bring
together the two key aspects of sexual health, individual choice
and collective responsibility, if it is to meet the diverse needs
of a varied population. The draft Strategy is eagerly awaited
for consultation.
The Government has also put in place a comprehensive
programme to reduce the number of conceptions amongst under 18s
and to provide better support to teenage parents. The programme
is still in its early stages of implementation. fpa welcomes its
co-ordinated approach. However, we believe that the Government
will only be successful in achieving its objectives if efforts
to reduce teenage pregnancy and support teenage parents take place
within the broader context of promoting young peoples' health,
including their overall sexual health.
Sex education has been clearly identified as
a significant component of the programme. While the Sex and
Relationship Guidance issued by the Department for Education
and Employment in July 2000 is a great improvement on previous
guidance, it is equivocal and ambiguous in a number of important
respects. In particular, it does not provide the necessary support
to primary schools to ensure that children receive clear information
about sex and relationships at an early age instead of absorbing
confused messages from the media and their peers.
KEY AREAS
FOR THE
SEXUAL HEALTH
STRATEGY
Encouraging a more mature attitude to sex
It is vital that the Strategy addresses ways
of creating and fostering a climate of opinion which encourages
responsible discussion about sex, sexuality and sexual health.
A more supportive climate of openness would enable parents, carers,
teachers, social workers, health professionals, youth workers
and all other relevant professionals to feel more confident about
talking to children about sex. It would also encourage people
of all ages to seek the advice, help and support they need. The
climate of opinion will be crucial to the success of the Strategy
because of its influence on the ability of individuals, communities
and the government to take the actions needed to achieve results.
The media plays a significant part here. It is essential that
steps are taken to maximise the positive aspects of the media's
role.
Sexual health as a mainstream issue
Sexual health is often "marginalised"
in relation to other aspects of sexual health. This not only contributes
to the negative social climate described above but can also have
an impact on local decision making about service provision and
professional training which may be discriminatory, judgmental
or ill-informed. If sexual health is to be fully addressed, it
is necessary to involve the broad range of professionals whose
role encompasses aspects of sexual health, even if they do not
see themselves as "sexual health" professionals.
Quality services
The standard of all sexual health services varies
enormously from the outstanding to the dreadful. Far too many
people seeking advice are being failed by services which are not
sufficiently sensitive to their circumstances. The range of services
must be sufficient to meet the needs of the general population
as well as marginalised and hard to reach groups. Staff must be
non-judgmental, sympathetic and well-informed.
Professional training
Working in sexual health requires particular
skills and competencies. In addition to clinical and technical
ability, communication skills and sensitivity to different cultures
and attitudes are central. These areas need to be addressed in
both initial training and in continuing professional development.
Sufficient resources must be made available to ensure that the
necessary training is provided.
Training for teachers and others providing sex
and relationships education in schools is a major priority. Lack
of a sufficient number of trained staff is the most significant
barrier to the provision of effective sex education. The Department
for Education and Employment should make this a priority area
and allocate the necessary resources to it.
Confidentiality
The sensitive nature of sexual health makes
confidentiality crucial for many service users but this is an
area where there is a great deal of confusion. The Teenage Pregnancy
Unit is addressing the issues as they affect young people. However,
the needs of other service users must not be overlooked.
Clarification is required for all professionals
who work within sexual health. Clear information needs to be effectively
disseminated and well understood by professionals. Confidentiality
obligations should be incorporated into quality standards and
professional training. Every service should have a policy about
confidentiality which accords with professional codes of practice.
The policy should be explained to service users and potential
users.
NHS structures
Organisational and structural divisions within
and between specialist and generalist services frequently act
as barriers to the provision of effective services. Joining up
the range of sexual health services—pregnancy testing, contraception,
abortion, emergency contraception, genitourinary medicine, HIV/AIDS,
the sexual health aspects of primary care and health promotion—is
made more difficult than it should by different commissioning
arrangements and funding mechanisms and clinical "turf wars".
The fact that genitourinary medicine, family planning and abortion
services may be in different NHS Trusts exacerbates the difficulties
and works against effective integration of services to meet user
needs.
The introduction of Primary Care Trusts provides
an opportunity to improve the situation. PCTs will need to have
sufficient expertise and commitment to realise their potential
in this area. Government recognition of and support for this aspect
of their role will be essential. PCTs should have responsibility
for ensuring a comprehensive sexual health service is available
in their area. They should undertake a full needs assessment and
review the range of professional skills and services available
to meet these needs. Duplication and gaps in provision should
be identified and a strategy developed to remedy them either by
changes in existing services or by allocating additional resources.
Each PCT should ensure that national evidence based quality standards
underpin the services provided in its area and that confidentiality
and choice is protected.
Research and data collection
While there is excellent data collection on
some aspects of sexual health, in other areas there is a paucity
of data as the basis for policy and service development. Monitoring
and surveillance in sexual health is currently disadvantaged by
the separate collection of data on different outcomes (conceptions,
births and abortions, sexual transmitted infections, HIV and AIDS)
and the lack of compatibility between them. The development of
positive, non-disease or pregnancy-focused indicators could provide
a means of monitoring the success of measures to improve sexual
health which looks beyond the mere absence of negative outcomes.
Information provision
There is still considerable ignorance amongst
all age groups about sex and sexual health. Therefore, the provision
of unbiased, authoritative information, in a variety of formats,
is essential. Research with service users repeatedly confirms
that they value the advice they receive from a sexual health professional
being backed up by written information that they can refer to
after the consultation. The provision of such information should
form part of the quality standard for sexual health services.
Experience with the Contraceptive Education
Service shows that a national charity can be a very effective
provider of information both in terms of quality and cost effectiveness.
Each year the demands on the Service rise, in terms of both the
quantity and content of inquiries. It has expanded its expertise
as far as possible within existing resources to meet these needs.
In the future, we would like the Service to be funded so that
it can provide coverage of all sexual health issues and meet the
needs of specific groups such as women facing unintended pregnancies.
National campaigns
There is considerable uncertainty about how
national sexual health campaigns are to be undertaken in the future.
Yet these have an important part to plan in raising public awareness
of issues and over the longer term, in influencing behaviour.
The Health Education Authority had a sexual
health team with considerable expertise which provided back up
to the major national campaigns funded by the Department of Health.
That team has been disbanded and now the only similar groupings
are within the small number of national sexual health voluntary
organisations. Although there is considerable capacity within
the Department of Health to commission campaigns, in general it
is more effective for campaigns to be undertaken by organisations
that have specific expertise in the area concerned so that follow
up over a long period can take place.
There is an urgent need for further campaigns
on a number of aspects of sexual health such as sexually transmitted
infections. A campaigns strategy needs to be developed and funded.
Such a strategy should utilise the knowledge and strengths of
the national sexual health organisations.
CONCLUSION
Sexual health is a neglected area of Public
Health where policy development has all too often been led by
high profile media issues rather than the needs of the population.
As this paper demonstrates, the present unsatisfactory state of
sexual health in the UK and the uneven quality of sexual health
services means that action is urgently required so that adequately
funded, integrated provision is available.
fpa welcomes the Government's decision to develop
a sexual health strategy but we are concerned that the draft has
not yet been published for consultation. We urge the Committee
to impress on the Government the need for immediate publication.
January 2001
REFERENCES
The Economics of Family Planning Services, A
McGuire and D Hughes, fpa 1995.
The fpa's Guide to Commissioning Sexual Health
Services, fpa 1998.
fpa's Guide to Commissioning Sexual Health Service
for Young people, fpa 1999.
Individual Choices, Collective Responsibility:
Sexual Health, A Public Health Issue, Maria Duggan and Anne Weyman,
fpa 1999.
Sexual and Reproductive Health and Rights in
the UK: Five Years on from Cairo Anne Weyman, Marge Berer and
Amy Kapczynski, fpa 1999.
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