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Select Committee on Health Third Report


2  WHAT IS SEXUAL HEALTH?

Definitions

15. Sexual health goes well beyond the medical model of the treatment of disease. The World Health Organization definition of sexual health captures this point:

16. Nevertheless, our inquiry was prompted by concerns expressed to us about the mounting levels of disease and the persistently high levels of unwanted pregnancy. We have attempted to look at the wider antecedents of these problems by exploring issues of sex education and lifestyle in young people. We have also paid some attention to the issue of sexual dysfunction, though we are aware that this neglected problem would merit an inquiry in itself.

Sexual health and health inequalities

17. As Professor Michael Kelly, Director of the Health Development Agency (HDA), pointed out, "the inequalities in health repeat themselves as inequalities in sexual health."[4] According to the Department:

    The highest burden is borne by women, gay men, teenagers, young adults and black and ethnic minorities. The rates of gonorrhoea in some inner city black and minority ethnic groups are ten or eleven times higher than in whites. HIV infection also has an unequal impact on some ethnic and other minority groups. Britain's African communities have been particularly badly affected by HIV/AIDS, with high rates among both adults and children. There is some evidence to suggest that chlamydia infection rates are associated with levels of deprivation.[5]

18. Research using the Office for National Statistics Longitudinal study has shown that the risk of unintentionally becoming a teenage mother is ten times higher among girls in social class five (manual unskilled) than in social class one (professional). Children in care and children of teenage mothers are also more likely to become teenage mothers, as are girls of Bangladeshi, Pakistani and Afro-Caribbean origin. Data also suggest that those girls who have higher educational aspirations are more likely to opt for an abortion.[6]

19. While little research has been carried out into the relationship between unintended pregnancy and social or ethnic grouping in older women as opposed to teenagers, statistics about abortion show that unintended or unwanted pregnancy affects the full age­range of women, although it is most common in the 20­25 age group.

20. The PHLS offers a similar analysis: young heterosexuals, men having sex with men and minority ethnic groups are at increased risk. Their figures for 1996-2001, and other sources, support the suggestion that in sexual health there are serious health inequalities:

  • of females with gonorrhoea and 36% of females with genital chlamydial infection were under 20 years of age: among 12 to 15 year old females diagnosed with gonorrhoea, almost a quarter will return with another episode of the disease within a year.
  • of diagnoses of gonorrhoea were in men having sex with men.
  • The rates of gonorrhoea among some inner city black and ethnic minority groups are ten or eleven times higher than among whites.[7]

21. Dr Peter Weatherburn, Director of SIGMA Research, a specialist sexual health and HIV health promotion research unit affiliated to the University of Portsmouth, described the difficulties associated with providing services for those groups disproportionately affected by HIV and AIDS:

    It is still very much the case that HIV follows the fault lines of society. Marginalised groups are affected by HIV. We mainstream the way we provide services around HIV and HIV prevention but it is still an infection that fundamentally occurs amongst groups that are marginalised from society or otherwise socially excluded.[8]

22. As Mr Nick Partridge of the Terrence Higgins Trust pointed out, these marginalised groups—those living in poverty, those who have been prisoners or young offenders, sex workers, those from ethnic minority communities, those who feel that their sexuality excludes them from their family or community — often have complex needs in clinical and social care settings, but do not access the health and social care system.[9]

23. Although the general demand for HIV/AIDS services in rural areas tends to be lower than that in urban centres, the needs of those people who are HIV positive may be all the greater. We received written evidence from Ruth Webb, an HIV positive mother of two living in West Sussex who had encountered great difficulties in gaining access to health advisers, community nurses and consultants. Mrs Webb also provided evidence of the stigma and myths still associated with HIV:

    I quote a well-educated gentleman speaking to me recently, whilst unaware of my HIV positive status: "we're immune in this country, so we don't have to worry about HIV. The only people who have it were infected somewhere else."[10]

24. In oral evidence to us, HIV/AIDS service providers expressed concern that people outside the urban centres where prevalence of HIV is high, might suffer through late diagnosis or through lack of local services. Dr Simon Barton, Clinical Director of HIV and Genito-urinary Medicine at the Chelsea & Westminster Hospital, told us that:

    The message that HIV needs to be considered in the diagnosis of somebody who goes into a district general hospital with a fever and pneumonia is an essential message which we need to keep getting across ... that is why we need better networks of care where every unit, wherever people are, is linked in to obtain specialist access, information and help.[11]

25. Dr Belinda Stanley from North Cumbria Acute Hospitals NHS Trust identified a general problem with services in low-prevalence, rural areas: "patients' reluctance to complain in rural areas because of associated stigma may give an inaccurate impression of satisfaction with the service being tendered."[12]

26. HIV compounds health inequalities for people who may already feel socially excluded. It also creates health inequalities for those living in areas where prevalence of stigma is higher than prevalence of HIV itself and where access to services and support is difficult.

27. Throughout this inquiry we heard much from service providers about the difficulties experienced by patients in terms of access, waiting times, and clinic premises and facilities. In light of this evidence it is striking that few, if any, patients complain about the unacceptable conditions under which they seek and receive diagnosis and treatment. Given the stigma around sexual problems, and given that those groups most affected by sexual ill health tend to be those whose voices are not heard in society as a whole, we can appreciate why patients might feel reluctant or even unable to complain. Primary Care Trusts need to make themselves aware of the patient's experience of sexual health services and work to improve this experience. Patient forums may be a route through which this could be undertaken.

Sexually Transmitted Infections

28. Sexually transmitted infections (STIs) are infections whose primary route of transmission is through sexual contact. STIs can be caused mainly by bacteria, viruses or protozoa.[13] They now represent a major public health problem and are among the commonest forms of illness, even death in the world today with far reaching social and economic consequences, particularly in the developing world. STIs cause considerable reproductive morbidity and poor health outcomes, including pelvic inflammatory disease (PID), infertility, ectopic pregnancy, neonatal disorders, cervical cancer and death, and about 12% of women with untreated chlamydia develop infertility after a first episode of acute infection rising to 70% after three different episodes.[14] As well as the physical impact of the diseases there is also "significant psychological morbidity"[15] caused to patients, together with social problems arising from stigmatisation. The general level of social stigma attaching to these conditions makes people reluctant to come forward for treatment and demands high levels of privacy and confidentiality in treatment services.

CHLAMYDIA

29. Chlamydia is the commonest bacterial STI in the UK. It is often undiagnosed since it is asymptomatic in 70% of infected women and 50% of infected men.[16] In women chlamydia may cause inflammation of the cervix, abnormal vaginal discharge, pain in the pelvic region, intermenstrual bleeding and burning sensations on urination (dysuria). If left untreated chlamydia in women can lead to PID, ectopic pregnancy[17] and infertility. Chlamydia can cause conjunctivitis in adults; babies born to infected mothers can develop conjunctivitis or pneumonia soon after birth. Symptoms in men include difficulties in urination, discharges from the penis, itchiness and tenderness.[18] The duration of the infection if untreated may be a year or more. Testing for chlamydial infection is by means of urethral samples in men and women, or cervical samples, urine samples or self-administered vulval swabs in women. Treatment is by antibiotics, and all partners should be seen and treated if infected.

30. Levels of awareness of chlamydia are low with one recent survey suggesting that almost three quarters of those aged 16-24 had never heard of the disease.[19]

GONORRHOEA

31. This is an infection caused by the bacterium Neisseria gonorrhoeae. Gonorrhoea is similar in its clinical presentation to chlamydia. In men gonorrhoea causes pain on urination and a penile (urethral) discharge, but may occur without symptoms. In women it normally produces only mild symptoms or no symptoms. In women gonorrhoea may spread to the fallopian tubes and can cause PID. If left untreated this condition may lead to scarring of the fallopian tubes, ectopic pregnancy and infertility. Rectal infection in men and women may lead to painful bowel movements, blood in the faeces, anal itching and discharge. Gonococcal infection can be transmitted during birth and cause conjunctivitis in babies. Although antibiotic treatment usually leads to a complete cure there is increasing concern about the development of antibiotic resistant strains of the bacterium.

SYPHILIS

32. Syphilis is caused by the bacterium Treponema pallidum. It has traditionally been classified into early infectious and later non-infectious stages. Early syphilis has two stages, primary and secondary. The incubation period for primary syphilis is approximately 9-90 days after sexual exposure. In the primary stage, lesions appear at the site of inoculation, which is normally the genital area. The lesion starts as a red spot which breaks down into an ulcer or chancre, which is often painless and unnoticed by patients. A secondary stage appears four to eight weeks after infection. The most common manifestation is a widespread red rash on the trunk, palms, leg, soles, face and genitalia. Again, some individuals will not be aware of symptoms. If primary and secondary stage syphilis are not treated about two thirds of patients will develop late effects of the disease, tertiary syphilis. About 10% will develop infection of the central nervous system, a further 10% of the heart and 15% lesions of the skin and bone. These severe complications may lead to disability and even death. Syphilis in pregnant women often leads to miscarriage or stillbirth; live babies born to syphilitic mothers may show signs of congenital syphilis. Treatment is by antibiotics and long-term follow up is essential to ensure that the infection has cleared.

GENITAL WARTS

33. These are the commonest of all viral STIs and are almost always transmitted by sexual contact. They constitute an infection of the skin and mucous membranes caused by the human papilloma virus (HPV). Small lumps with irregular surfaces are found on the penis, scrotum, anus, rectum, vulva, vagina, cervix or in the mouth. Often these are small and not easily detected. They can cause itching and irritation. The commonest types of genital wart rarely lead to complications but the virus types HPV-16 and HPV-18 are associated with the subsequent development of cancer of the cervix. Flat warts on the cervix are not usually apparent to the naked eye. However, they are detected in smear tests. Treatment of genital warts is by the application of chemical paint to the wart or freezing of the wart. Some treatments can be applied at home while others require a health worker.

GENITAL HERPES

34. This is a common infection caused by the herpes simplex virus type 2 or type 1 (the usual cause of cold sores). Genital HSV 1 herpes is commonly acquired through oral genital contact; type 2 typically affects the genital area and is most frequently a result of penetrative intercourse. Symptoms include small blisters in the genital area which rapidly break down to leave painful ulcers. Other symptoms include pain or difficulty in passing urine. Some patients may develop headache and fever. The virus can be spread by skin to skin contact at any time when there are blisters or other symptoms. A first episode of herpes during late pregnancy is potentially dangerous to the baby during labour. Herpes is a life-long chronic condition which cannot be cured; but the severity of infections, and likelihood of recurrent infections, can be decreased by the use of antiviral drugs taken daily in small doses.

HIV/AIDS

35. Human Immunodeficiency Virus or HIV belongs to a group of viruses called retroviruses. Viruses infect cells by copying their genetic material into the genetic material of the human cells. HIV prevents the immune system from working properly by infecting CD4 cells (also known as helper T-cells) which coordinate the immune system's fight against infection. CD4 cells are a type of lymphocyte (a white blood cell) that helps to identify, attack and destroy specific bacteria, fungi, and other germs that infect the body. They help regulate the production of antibodies.

36. In general, HIV infection is detected by an HIV antibody test. The first test to be conducted, usually on blood, but possibly on saliva, is an ELISA (enzyme linked immunosorbent assay) test which uses an enzyme to detect the presence of antibodies. Since this test can sometimes be positive even when someone is not infected—a 'false positive'—a second enzyme test called the Western Blot is carried out. This test yields more detailed results but is not used exclusively because the ELISA test can be done much sooner after infection with HIV than the Western Blot test. There are also a number of tests which can look for the virus or parts of the virus itself, for damage to the immune system, or for other aspects of the body's response to the effects of the virus. The diagnosis of AIDS is only made when a patient develops an opportunistic infection or cancer which indicates the presence of severe underlying immune deficiency. Such opportunistic infections or cancers are usually diagnosed after a patient has been diagnosed as HIV positive. However some patients learn of their HIV positive status only when they become seriously ill with one of the opportunistic infections or cancers and present at hospital.

37. The major modes of transmission of HIV are through sexual transmission, vertical transmission (mother to child), and through blood and blood products including the use of contaminated needles by intravenous drug users. Once the virus has infected a human being there are three phases of HIV infection: Primary HIV infection; the long term (chronic) asymptomatic phase; and overt AIDS.

38. Primary HIV infection is a transient condition appearing two to four weeks after virus exposure. Although it can occur without symptoms, 40-90% of patients develop a symptomatic illness, which is flu-like but sometimes associated with rashes and more severe symptoms. Patients may be unwell for up to two weeks. During this period of time the patient may not have produced sufficient HIV antibodies to become HIV positive on the tests routinely used. Patients become HIV antibody positive from six weeks to six months (usually from six to twelve weeks) after exposure.

39. Primary HIV infection is then followed by a long phase during which neither signs nor symptoms of illness are present. This is the long term (chronic) asymptomatic phase. The median length of time of this phase is around ten years. The patient is HIV positive but the levels of virus in the blood and the number of CD4 cells tend to be relatively stable and only change slowly over this period of time. As the immune system is slowly impaired the number of cells which help protect the patient from various disease entities and the CD4 cell count starts to drop below 200 cells per ml. At this point the risk of developing life-threatening opportunistic infections or tumours increases rapidly, and the patient may pass into the overt AIDS stage. These opportunistic infections and tumours, which would not normally arise in people whose immune systems are intact, are often called AIDS-defining illnesses.

OTHER CONDITIONS

40. Among a wide variety of other conditions presenting to clinics and requiring specialist investigation and treatment are urinary tract infection, dermatological and psycho­sexual problems and infections caused by fungi such as vaginal candida (thrush). In addition, the viruses hepatitis B can be sexually transmitted, though not normally by vaginal intercourse; hepatitis A and C are rarely sexually transmitted.[20]

Co-infection issues

41. It is now recognised there is a synergy between most STIs and HIV (particularly ulcerative and inflammatory conditions). The understanding that both HIV transmission and acquisition are enhanced by the presence of STIs has resulted in the development of overarching control programmes for sexual health which include both HIV and STIs.

42. Co-infection with STIs and HIV is now common, and can create difficulties in treatment. Up to 50% of homosexual men diagnosed with infectious syphilis in London are HIV positive, and co-infection with HIV and tuberculosis (including multiple drug resistant strains) is becoming more prevalent, particularly in those from ethnic minorities.[21] This may help to explain the disproportionate burden of HIV in settings where the prevalence of STIs is high. Data from the Unlinked Anonymous HIV Sero-Prevalence Survey show a marked increase in the proportion of known HIV positive homosexual men diagnosed with acute STIs. This highlights concern that HIV positive individuals can play "an active and often substantial role" in the transmission of STIs and in the growth of syphilis outbreaks in particular.[22]

Unintended pregnancy and teenage pregnancy

43. The Strategy states that "Sexual health is not just about disease. Ignorance and risky behaviour can also have profound social consequences."[23] Teenage pregnancy is frequently (although not always) unintended,[24] is generally perceived as a problem, and has well documented links with ill health, low educational levels and ongoing poverty. The focus in recent years on the issue of teenage pregnancy has tended to divert attention from the broader but equally problematic issue of unintended or unwanted pregnancy across all age groups. Ian Jones, Chief Executive of the British Pregnancy Advisory Service told us that in 2000, some 79% of women having abortions were not in fact teenagers.[25] Unintended pregnancy at any age can have high social and economic costs and may result in abortion which can have adverse health effects for the patient, as well as being costly for the NHS.

Sexual dysfunction

44. Any type of sexual dysfunction is distressing and can affect either sex at any age. Most commonly, men are concerned about premature ejaculation, failure to obtain or maintain an erection and lack of libido. Women's concerns are less widely publicised but cover problems such as sexual disinterest and failure to achieve orgasm. The pharmaceutical company Lilly UK cite US research data to suggest that up to 30% of the population will experience some form of sexual dysfunction and that as many as a third of men suffer from some form of erectile dysfunction.[26] Specialist services are scarce and have tended to focus on erectile dysfunction. The psychological distress caused by sexual dysfunction can be profound and the extent of this problem, we believe, needs to be recognised more openly.


3   See www.who.int. Back

4   Q 432 Back

5   Strategy, p 9 Back

6   Q 432 (Professor Mike Kelly, Health Development Agency) Back

7   Ev 58-59; www.phls.co.uk;Strategy, p 9 Back

8   Q 358 Back

9   Q 366 Back

10   Ev 400 Back

11   Q 669 Back

12   Ev 395 Back

13   Most sources now refer to STIs rather than STDs (Sexually Transmitted Diseases) or venereology. Back

14   See : Chlamydia- general information Back

15   Ev 324 (Dr Beng Goh, GUM physician for North East Thames Association for GUM) Back

16   Chief Medical Officer's Advisory Expert Advisory Group on Chlamydia trachomatis, 1998 (hereafter EAG Report) Back

17   Chlamydia has been estimated to account for 40% of ectopic pregnancies, a condition which is the leading cause of maternal death in pregnancy in industrialised countries during the first three months of pregnancy (EAG Report). Back

18   This and other information on the pathology of STIs is sourced from Sexually Transmitted Infections, BMA Board of Science and Education, February 2002, together with material prepared for the Committee by Professor Michael Adler and Dr Anton Pozniak, advisers to this inquiry. Back

19   Cited in EAG Report. Back

20   British Medical Association, Sexually Transmitted Infections, (2002) p 6 Back

21   Ev 389 (The Specialty Societies for Genitourinary Medicine) Back

22   Unlinked Anonymous Surveys Steering Group. Prevalence of HIV and hepatitis infections in the United Kingdom. London: Department of Health, 2001 Back

23   Strategy, p 8 Back

24   K Kiernan, "Transition to parenthood: Young mothers, young fathers-associated factors and later life experiences", Welfare State Programme, Discussion Paper WSP/113, London School of Economics, 1995 Back

25   Q176 Back

26   Ev 331 Back


 
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Prepared 11 June 2003