1.Good sexual health is a vital aspect of overall health and wellbeing. That is helped by easy access to high quality information and sexual health services. Although the top line figures for sexual health appear positive at first glance—overall sexually transmitted infections (STIs) and teenage pregnancies are falling—they mask a number of worrying underlying issues and inequalities. Some concerning trends have been highlighted to us, as has the tendency for poor sexual health outcomes to fall disproportionately on certain groups.
2.Overall diagnoses of sexually transmitted infections (STIs) fell by 7% from 2013 to 2017. There has been a significant decline in new HIV diagnoses, thanks to a sustained long-term effort and more recently the introduction in some areas of PrEP. There has also been a fall in genital warts, due to HPV vaccinations, and chlamydia, since the introduction of the chlamydia screening programme. There are worrying trends however for the diagnoses of syphilis and gonorrhoea, which have increased by 20% and 22% respectively from 2016 to 2017, in line with significant rises over the past decade. Dr Williams, President of the British Association for Sexual Health and HIV, described this increase as “much more than we had anticipated for the 21st century”.
3.Poor sexual health can lead to serious personal long-term health consequences for individuals. As Ian Green, Chief Executive of the Terrence Higgins Trust, told us, “sexual health is an issue for most people, but there are clear groups that are disproportionately affected.” The impact of STIs is greatest in young people. Among those aged 15 to 24, men are twice and women six times as likely to be diagnosed with an STI than their counterparts aged 25 to 59. Men who have sex with men (MSM) are also disproportionately affected by STIs. In 2017, 84% of syphilis diagnoses and 64% of gonorrhoea diagnoses in men were in MSM. Over half of those diagnosed with HIV in the UK in 2017 were gay or bisexual men. There are also disparities in the impact of STIs on minority ethnic groups. The rates of gonorrhoea and chlamydia in black and minority ethnic (BME) populations are three times that of the general population, and the rate of the STI Trichomoniasis is eight times higher. Minority communities constitute 14% of the UK population but have a burden of late HIV diagnoses of 52% and 40% for people accessing HIV services. Although rates of HIV are declining in MSM overall, this is not the case in all communities. The situation is worse for BME women. 80% of women living with HIV are BME, and 62% are of African heritage.
4.Anti-microbial resistance (AMR) is becoming a major issue in the treatment of gonorrhoea. Last year there was the first case globally of gonorrhoea for which no drugs were available, and in the last three months two further cases have arisen for which we heard there were significant issues around treatment. If the issue of AMR is not addressed, gonorrhoea will no longer be a disease that is curable with one injection. Public Health England told us that “resistance to the antimicrobials used to treat gonorrhoea is a global public health concern.” BASHH point out that the cost of treating a resistant gonorrhoea infection is around six times higher than a standard gonorrhoea infection.
5.Mycoplasma genitalium (MG) is another emerging threat to sexual health. This newly discovered STI has often been wrongly diagnosed as chlamydia. Diagnostic testing for this condition is not routine within sexual health services, and where not properly identified and treated it can develop resistance to antibiotics. Some of the antibiotics used to treat mycoplasma genitalium are already ineffective due to AMR. The British Association for Sexual Health and HIV warned that “if current practices do not change, Mgen will become a superbug, resistant to 1st and 2nd line antibiotics, within a decade.”
6.Whilst the teenage pregnancy rate has fallen consistently since 2007, we heard from witnesses that in some areas, including Bradford and Manchester, it is beginning to increase, particularly amongst deprived groups. After over a decade of steady decline, the abortion rate increased from 16.0 per 1,000 women in 2016 to 16.7 per 1,000 women in 2017. Abortion rates in the over 30s, however, have increased throughout this period. Within this overall trend, there are regional inequalities and a north-south divide. The three northern regions of England have the highest rates of teenage pregnancy, and rates in the North East are 64% higher than in the South West.
7.We received over 90 submissions following our call for evidence, from a broad range of groups and individuals. We held two oral evidence sessions in which we heard from a range of stakeholders working in sexual health, including national organisations representing providers and commissioners and charities, along with senior officials and the Minister. We are very grateful to all those who gave oral and written evidence to us.
8.We were particularly keen to hear from individuals with experience of using sexual health services, as given the sensitivities around sexual health, it is an area where services users may have particular issues having their voices heard:
One of the issues around sexual health and contraception access, of course, is being brave enough to stand up and talk about it. If you have a bad experience with your hip replacement, you complain to your GP, the CCG board, the hospital, or whatever. If someone feels exposed and vulnerable because of their cultural or social background, they will find it much harder to stand up and say, “I had a really bad deal. I had to go through these hurdles and I could not get that contraception, and I had to have an abortion” with the embarrassment of all that. There isn’t a local voice in local areas saying that they need to get the service sorted out better.
9.We therefore ran an online survey, from which we heard directly from nearly 400 service users about their experience of using sexual health services and improvements they would like to see. We have used quotations from service users to illustrate our points throughout the report, which can be found in ‘case examples’ boxes, and are indebted to those who took the time to share their experiences.
10.We are also extremely grateful to the service providers and commissioners who contributed to the inquiry. On Monday 11 February 2019 we visited two sexual health services in Plymouth—Sexual Health in Plymouth (SHiP), a hospital-based clinic, and The Zone, a community based, young people’s service. We also held a roundtable with a range of people working in sexual health in Plymouth. More information about our visit can be found in Annex 1.
11.Plymouth was also the venue for a series of highly informative focus groups we held with 20+ people working in sexual health drawn from across England. We are extremely grateful for the time they gave, the distance they travelled, and the frank and thoughtful contributions they made. More information about the visit and focus groups can be found in Annex 2.
1 DHSC ()
4 Public Health England ()
7 PHE –
8 PHE –
9 PHE –
10 Marion Wadibia
11 Marion Wadibia
12 Marion Wadibia
14 Public Health England ()
16 British Association for Sexual Health and HIV / British HIV Association ()
18 Office for National Statistics,
20 , Health and Social Care Committee
Published: 2 June 2019