Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 320-340)



  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 improved—perinatal mortality rates, maternal mortality rates—and 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 is acceptable.

Jim Dowd

  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 it—I 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 marriage—those changes occurred before the technological developments; so that the—

  325. And the social developments that went with them.
  (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.

Julia Drown

  327. Do these figures include the number of gay partners?
  (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 this issue.

  328. It would be helpful as there is such a massive difference.
  (Professor Johnson) Yes.

Jim Dowd

  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 already—most 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 report.

  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?

Andy Burnham

  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.

Dr Taylor

  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 population—and 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 field—and 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?

  335. Absolutely.
  (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 service—because it is the laboratories that make the diagnoses. You have to make sure you get the contact tracing right. STDs—because 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 rates—so 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.

Sandra Gidley

  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 on—or 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 important—things like measures of social environment like housing or single-parent families and so on. The educational environment probably is important and perhaps education—not sex education necessarily but broad issues of educational standards—is 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 soaps—I 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 to them.
  (Professor Johnson) We need to find a way to get to the boys.
  (Dr Fenton) Absolutely.

Julia Drown

  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 media.

  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.

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