Examination of Witnesses (Questions 320-340)|
WEDNESDAY 17 JULY 2002
320. Do you think we have a more risk-taking
kind of society in that people have more extreme behaviour and
people are going further than they used to?
(Professor Johnson) I am not sure that one can generalise
about those things. There is a whole area of study about risk-taking
behaviour, which suggests that, if you make things safer people
will take more risk. This is the theory of risk compensation.
There are many aspects of sexual health that have greatly improved,
and one or two have massively improvedperinatal mortality
rates, maternal mortality ratesand septic abortion are
greatly reduced. One has to take that view of the checks and balances.
It is difficult to give a firm answer.
321. Whatever the differences of methodology,
it shows that age of first sexual intercourse amongst women is
not decreasing and plateau-ing. Am I right in thinking that has
happened in other European countries and in the United States?
In the early 1980s it happened in other countries and the USA
in the late nineties, and in Britain and New Zealand it occurred
in about 1983.
(Professor Johnson) I am not sure that is quite the
conclusion we came to. Around 50 per cent of young people nowadays
have had intercourse by their seventeenth birthday. In Kaye Welling's
paper in The Lancet, in that she concluded that the increase
in the proportion of women reporting first intercourse before
age 16 does not appear to have continued throughout the past decade.
We are beginning to see that there is some levelling off in this
decline of the age of first intercourse. It is very difficult
to produce comparative figures across Europe and the United States,
simply because very few countries have these data sets to make
a coparison. You will see various surveys, but very few
322. Is Natsal better than what most are doing?
(Professor Johnson) I think it is fair to say that
Britain is the only country in the world to have done two surveys
of this magnitude that could be compared. The only study in the
States was of under 4,000 people.
323. It strikes me it is an enormously valuable
piece of work. Two questions flow from that: is there a proposal
to repeat it? If so, will it be in 2010; and, if so, is that not
too long? Is society not changing far more quickly?
(Professor Johnson) Having just published the paper
six months ago, we are a bit doutful at the thought of doing another
one right now, because these are very expensive surveys to undertake.
This one cost about £1.4 million. It raises a very important
question: how do we obtain behavioural surveillance data at a
level that is not prohibitively costly? The Communicable Disease
Surveillance Centre clearly has a surveillance system in place
for diseases, but we need to have surveillance for underlying
behaviour. We have some of that in London for gay men, but we
could achieve the sort of behavioural surveillance data by obtaining
data on sexual matters from some of the existing surveys in which
government currently invests. An example would be the Health Survey
for England, which is a survey undertaken every year, with funding
from the Department of Health. One way of trying to reduce the
costs of these big surveys would be from time to time to have
a module of key questions on sexual behaviour, which we have demonstrated
324. To refer back to the risk-taking aspect,
clubbing has declined markedly since the 1960s. We have seen the
growth of industrial clubbing, which is something else entirely;
but the risk assessment of itI got the impression that
the consequences now of the same sort of behaviour from 10-25
generations more ago is now much less severe than it was then,
and may have served to blunt people's awareness.
(Professor Johnson) As I said, the literature on risk
is about those checks and balances. Interestingly, if you take
a historical perspective, many of the changes in behaviour which
I have discussed, particularly the fall in the age of first intercourse
and the increase in sex before marriagethose changes occurred
before the technological developments; so that the
325. And the social developments that went with
(Professor Johnson) I would argue that those were
part of the social developments that drove the need for better
contraception, for better abortion facilities, which altered the
legislation on sexuality and so on. We are a very complex society.
We do try to diminish risk, and that is in a sense what some of
the developments in modern societies are about. There is less
risk in certain areas of our health and dramatic improvements
in life expectancy. I suppose that with infectious diseases generally
people felt in the 1970s, with antibiotics ,that we had somehow
licked infectious diseases, but they come back to remind us that
they are endlessly evolving. HIV has perhaps changed the balance
of the risks that people were prepared to take. Whether that is
good or bad is not for us to say.
326. If you are in a position where you acquire
any STI or anything else which is to all intents and purposes
untreatable, that might describe a course of action, as opposed
to knowing we may or may not contract it, but there are antibiotics
and all kinds of treatments that will affect your behaviour.
(Professor Johnson) I think that is what we saw in
the eighties for the AIDS epidemic. People should not think HIV
has gone away because it has not. We need to think carefully about
young people's sexual behaviour because a lot of women who were
having sex early expressed high levels of regret that they had
had sex too early. We should pay attention to that.
Andy Burnham: It is very interesting. You have
touched this a couple of times: you were asked the extent to which
changes in sexual behaviour amongst gay men occurred in the community.
327. Do these figures include the number of
(Professor Johnson) I would imagine those figures
were the ones taken from The Lancet paper. Are you asking
whether it was an equal number between men and women? You are
asking an academic and I would have to give you an academic response.
There is a discrepancy in any survey. Men always, on average,
reported a higher average than women. You have to think about
this. In a closed society, men and women should over a defined
time period report a similar average. Now, this is not a closed
population because we know that 16-44 year-old women tend to have
sex with older men, on average; and there is a complex factor
in those figures which means that you have to take account of
the age mixing pattern. So in the survey there are a higher proportion
of single men than there are single women, because women get married
early. We know that single status is a very strong predictor of
multiple partner change. I am sure this Committee does not want
to hear more about this, but I could give you a paper which addresses
328. It would be helpful as there is such a
(Professor Johnson) Yes.
329. You are describing heterosexual relationships
in the main, surely?
(Professor Johnson) They are in the main heterosexual
partners. The figures you are describing are actually
330. The rate of partners amongst gay men, for
example, is far higher than either for lesbians or the heterosexual
community at large.
(Professor Johnson) Yes. The other thing I should
say is about these large sample surveys, the mean number of partners
is heavily influenced by the small proportion with very many partners.This
is a very important thing about sexual behaviour, and you have
raised it alreadymost people have few partners and a few
have many. The top 1 per cent of distribution contributes very
disproportionately to the mean. You will always get people who
report hundreds or even thousands of partners in these large surveys
and they can shift the mean massively. One of the calculations
we have done is that if you under-sample women in the sex industry,
you are systematically missing that group of people who shift
the mean. Nevertheless, having said all that, to justify the difference,
I think you know that in society there are different constraints
upon our attitudes to women's sexual behaviour and men's sexual
behaviour, which may lead men to over report and women to under
331. It may also be the difference between what
men and women would include as "sexual encounter".
(Professor Johnson) Yes.
Julia Drown: You mentioned changes in sexual
behaviour. Is there anything else on that?
332. You mentioned complacency, referring to
unprotected sex. Is that a main behavioural change?
(Professor Johnson) I mentioned that there was increased
risk behaviour. I could not say that that is due to complacency.
I think there is increased risk behaviour in gay men and I think
that is a considerable concern. We do need to understand the methods
to try and prevent further HIV transmission.
333. Professor Johnson coped with those last
questions masterfully, so here is a much easier one! Looking at
the general level of knowledge in the population about STIs, particularly
chlamydia, what is the level in the populationand what
is the level of knowledge with GPs?
(Professor Johnson) I do not have figures at my fingertips,
but I think there have been surveys done which have suggested
that people are much less aware of chlamydia infection than they
are on other STDs. I think this is highly relevant to the sexual
health strategy and the proposals to engage primary care more:
you heard some of the complexities of the testing and how rapidly
the technology is changing, so if one wants to try and engage
primary care in a greater proportion of STDs diagnoses and achieve
better control through that mechanism, I think one would have
to invest in a considerable level of training around some of these
issues because it is a rapidly developing field. I think we need
to know a lot more about the amount of work that GPs are already
doing in this fieldand Dr Cassell has some recent data
on that. I think a lot more people go to their family doctors
in the first place with STD symptoms and consult and get referred
on to GUM than we previously recognised. There may be a great
opportunity to engage GPs more, but these are busy people and
one needs to invest in both training and in asking them to take
on this additional workload.
334. I am rather bothered because PCTs are clubbing
together for services like sexual health, and one can see the
position where the PCT that has that responsibility puts more
into it than the other PCTs, and that is worrying, I think. It
is taking away the urgency from the PCTs that do not have a responsibility
in a way.
(Professor Johnson) You mean because they have not
got a GUM clinic on their patch?
(Professor Johnson) This is a very complex area, but
it seems to be that if you are going to engage in primary care,
you have to provide the support, and you have to provide the very
close links with the GUM service and the laboratory servicebecause
it is the laboratories that make the diagnoses. You have to make
sure you get the contact tracing right. STDsbecause sexual
behaviour is not equally distributed and neither are STDs, and
there are very much higher rates in London, where one would want
to see greater investment in places with higher ratesso
this is not a case of equal investment across the different PCTs.
It probably does need some investment in places with high rates,
to try and get better services. If you want to get the GPs involved,
then you have to think how to provide that level of support.
336. Coming back to education and information,
it has been mentioned during today that young people are unaware
of many of these diseases or infections. Presumably, they lack
the information. Was there anything in the Natsal survey that
questioned the source of information about sexual matters? I would
be interested on hearing comments between the link information
and sexual behaviour. How does it impact?
(Professor Johnson) Broadly, we found that schools
now are the most important source of education for both boys and
girls but more important for boys than girls, in the sense that
girls tend to rely more on their parents than the boys do. There
has been an increase in the importance of lessons at school. Close
to 40 per cent of boys now report that as their main source of
information, and girls report their parents as a more important
source than the boys do. This is a difficulty in terms of causal
association, but we did find that those who reported that lessons
at school were their prime source of information were less likely
to have adverse sexual health outcomes in their teen years; in
other words, they were less likely to have teen pregnancies and
so on. I think there is a broader issue about people who have
teenage pregnancies: they tended to be young women who had low
levels of educational attainment. You would rightly say, is it
because they have had a baby that they will not get their GCSEs
and so onor is the other way round? I suspect both things
are going on, and we need better longitudinal studies to understand
that relationship. Low educational attainment was the strongest
association with teenage pregnancies. The family background was
less importantthings like measures of social environment
like housing or single-parent families and so on. The educational
environment probably is important and perhaps educationnot
sex education necessarily but broad issues of educational standardsis
important in this broader area. I would not like to attribute
cause and effect, but those are the associations.
337. Would you say that from that survey, if
we are looking at policy around these areas, that the impact of
education should be something that we should consider most seriously;
or are there other policy areas that we need to look at?
(Professor Johnson) I think one should try and unpick
this association between quality of education, educational achievement
and demand and for sexual health outcomes. There are other studies
which suggest that the availability of services locally are very
important, and awareness of local services, so that young people
can get the services and information they need. There is broader
literature on that and more detailed information, which you might
hear about in your session on health education.
338. I was interested in Dr Cassell's comments
about the media and there being an awareness in programmes that
are targeted towards young people. Was that a source of information
for young people, and would you agree with the comments of the
BMA that there should be more focused media awareness through
programmes like Eastenders, for example?
(Professor Johnson) There is some very interesting
data from CDSC looking at the impact of various media campaigns
on people coming into HIV testing clinics, as a measure of awareness.
The government campaigns did cause something of a blip, but the
thing that really kicked the rates up was the discussion on a
national soap. When these issues are raised on national soapsI
cannot remember the exact event because I am not an Eastenders
fan personally, but there was an event which caused a large change
in behaviour. I think that chlamydia may have featured recently
in a soap.
339. I would like to ask a very sexist question.
Was awareness better among females than males? Teenage girls are
avid readers of these dreadful magazines that my daughter used
to bring home. There were frequently quite serious information
messages in those. Boys do not read things in the same way and
I just wondered if that came through the survey.
(Professor Johnson) We did not ask about people's
knowledge about STIs in the surveys, so we do not know; but you
are absolutely right, a lot of the teenage pregnancy campaign
was through young people's magazines.
(Dr Tobin) We did a little study during the chlamydia
pilot. Before the pilot started we asked everybody coming into
GU medicine and family planning clinics in Portsmouth if they
knew about chlamydia.. Then we looked at what happened during
the one year, as to what they knew about chlamydia. We found that
in the targetted age group, ofe young women, knowledge was about
40 per cent. They knew a little bit about it at the beginning.
At the end of the study it was about 100 per cent. Obviously,
we could be said to be in an area where chlamydia screening was
all happening, so we did the same study in an area a long way
away where there was no chlamydia pilot going on; and the rate
of knowledge increased exactly the same. The figures were almost
identical. We asked them how they found out about it and it was
through girls' magazines and the television campaign at the time.
We also looked at the men to see what happened there, and found
the level of knowledge among men was about 20 per cent, and it
actually went down during the pilot. There is a role for the media,
certainly, and young girls' magazines are a very good way to get
(Professor Johnson) We need to find a way to get to
(Dr Fenton) Absolutely.
340. Is there agreement across the panel that
there has been a lack of high profile campaigns that continue
to tell people about risky behaviour, sexually transmitted diseases
and so on? Should that have been continuing?
(Dr Fenton) One of the things we have noticed anecdotally
over the last seven to ten years is the increasing sexualisation
of the media as well. It is not just girls' magazines, but it
is television as well. On the one hand, you are getting these
messages to start having sex earlier and having multiple partnerships;
but you are not having concomitant messages to say "use a
condom" or telling them to reduce the number of partnerships.
The balance is shifting. That is one of the issues of using the
John Austin: I thank all of our witnesses for
coming here this afternoon. If, when reading the transcript, you
feel there is anything you want to add, we are always willing
to accept further submissions.