101.Prevention is central to achieving good sexual health outcomes. Prevention covers both activities that encourage healthy behaviours and changes that reduce the risk of poor sexual health outcomes, for example countering the influence of pornography on what young people see as normal, which witnesses to this inquiry told us is increasing risk. Government’s rhetoric around prioritising prevention must translate into action in this area. Education is a key aspect of prevention, and Government’s plans for new Relationships and Sex Education (RSE) are an opportunity to correct a long-running inadequacy, and properly equip young people with the knowledge base they need to look after their sexual health.
102.Concerning trends in sexual health are driven not only by poor access to services, but by behavioural change. Significant increases in syphilis and gonorrhoea in particular have largely been attributed to behavioural factors. There has been a drop in condom use, with some 47% of people not using a condom for their first sexual experience with a new partner. These are complex social trends, differing by age, sexual orientation and perceived gender.
103.On our visit to The Zone, a young people’s community-based clinic in Plymouth, we heard that many young people are getting their education through pornography. This is informing their expectations of sex and influencing what they perceive as acceptable. Condomless sex, different types of sex, such as anal sex, and rougher sex have become increasingly normalised. These behaviours, without the use of appropriate protection, increase the risk of poor sexual health.
104.We also heard about changes in how people are meeting sexual partners. We were told that apps have led to more casual sexual encounters, which can mean there is less communication and less negotiation of safe sex, which increases STI transmission. The geo-spatial nature of these apps also means that STIs are increasingly passed between what would have otherwise been disconnected sexual networks. Dr Williams pointed out that apps can also make it difficult for an individual, if they find they have an STI, to inform their partner:
Part of the growth is how people access their sexual partners. I won’t blame the internet or apps, but it is often due to the fact that a profile disappears; someone meets up with someone, hooks up, and then the profile disappeared. It is impossible for that person then to inform the person that have had sex with about their condition, which means that they can go on unwittingly to transmit.
105.In the face of concerning behavioural trends, instead of gearing up to address them, Government and local authorities have deprioritised prevention. Professor Newton told us that:
The longer we neglect this aspect of the agenda, the more we will have behaviourally driven issues sideswipe us, such as chemsex.
106.As shown previously (figure 1), prevention has taken the brunt of cuts to the sexual health budget. There has been a 35% real terms reduction in local authority spending on sexual health advice, prevention and promotion between 2013/14 and 2017/18, compared to a 14% decrease in local authority spending on sexual health overall. Advice, prevention and promotion is inherently susceptible to disinvestment as, unlike STI testing and treatment and contraception services, they are not mandated services which local authorities are required by law to provide. At our roundtable in Plymouth providers and commissioners told us that it has been hard not to prioritise treatment services in the face of increasing demand and reduced funding. Treatment services were described as an “at-the-door pressure”—service users turn up and need to be treated. Prevention, meanwhile, was described as easier to lose sight of—these activities are less noticeable in the immediate term. Therefore it is particularly important to ensure that there is robust accountability for the provision of preventative services.
107.Disinvestment in prevention is short-sighted because pays for itself in a whole-system, total cost sense, but not necessarily for individual commissioners. Financial incentives for prevention are not lined up: one part of the system can do an excellent job preventing a poor sexual health outcome, but the savings made averting this negative outcome are gained in a different part of the system. For example, if a local authority prevents someone from acquiring HIV, the NHS reaps the benefit as it does not have to fund HIV treatment for this person. Conversely, if someone is not given good prevention advice and PrEP if applicable, and then acquires HIV, the NHS will pay the significant lifetime cost of treatment. Dr Menon-Johansson, Clinical Director of Brook, highlighted the need to address this, and stated that money saved through prevention should be put back into prevention:
Because the funding streams are not linked, people do not think about how prevention really does pay for itself. It is the best investment we have, and we need to make sure that the money comes back. Every time we stop another [case of] HIV, that money should be coming back into prevention services. We are talking millions of pounds over the country.
108.The lack of emphasis on prevention in sexual health runs directly against the Government’s ambition to prioritise prevention. This imbalance must be redressed, and Government’s stated position must translate into action. As we heard at our focus group in Plymouth, the Government must “put its money where its mouth is.” The service users we heard from reiterated this point (case examples 7). We welcome the Minister’s indication that prevention in sexual health will be a central part of the prevention Green Paper, and we expect the Government to set out in the response to this report how that commitment will be followed through into action, including the funding required to put it into practice.
Case examples 7: service user views on prevention
Government talks about prioritising prevention in its new NHS long term plan yet cut the public health budget weeks before – sexual and reproductive health care appears not to be a priority for the Government and therefore doesn’t receive the necessary funding to empower people to exercise informed choice and make responsible decisions regarding their own sexual and reproductive health. (heterosexual woman aged 25–35)
Source: Summary of survey responses received
109.Good education is a vital part of the sexual health prevention agenda. People must have the information they need to look after their sexual health. For example, they need to know that they should think about getting tested if they have condomless sex. We have heard examples of successful programmes. Professor Newton told us about Rise Above, a programme done with PSHE teachers which moves beyond the traditional approach and aims to equip young people with skills to face challenges around new technology and pornography. However, programmes such as these are not consistently available in all parts of the country. This was highlighted by the service users we heard from (case examples 8).
Case examples 8: service user views on education and information
I received lots of sex and contraception information at school and university which I rely on, and the fact that not everyone received the same as me shocks and terrifies me. (bisexual woman aged 18–24)
Where I live in London, I often come across public information adverts (especially regarding testing for HIV and other STDs), which I believe are helpful for informing about services available and reducing the stigma around these things. However, I don’t think I have ever come across such a campaign in the rural area where my family home is and where I live when I am not studying. Growing up in the countryside, I felt that sexual health information and services were much less accessible. (bisexual woman aged 18–24)
Source: Summary of survey responses received
110.We heard that the “glaring omission” in the current system is that young people are not being educated in a way that helps them make intelligent choices. As stated previously, young people are getting their education through pornography, which has troubling effects on sexual behaviours and health. The current lack of good relationships and sex education (RSE) at school means people are at risk from an early age, as they are not building a strong knowledge base from which to make informed decisions throughout their life. As Ian Green, Chief Executive of the Terrence Higgins Trust, told us:
It is absolutely vital. If we want a society where good sexual health is a right for all, it starts with good-quality relationship and sex education.
111.We are pleased that the Government has brought forward plans for RSE. This is a welcome initiative that has been a very long time coming and presents an opportunity to ensure young people are given the knowledge, skills and values they need to look after their sexual health. It will be important to ensure the substance of this is up-to-scratch: we have heard “the devil is in the detail”. Evidence to our inquiry argues that this education must be age-appropriate, culturally competent, strong on diversity and inclusion, and up-to-date with medical advances. It also indicates that RSE should link up with local authorities and local providers to enable teaching to be informed by local health priorities and point to local services.
112.RSE must be delivered by people who are adequately trained to do so. On our visit to Plymouth we heard that “you wouldn’t want just anyone to teach maths, so why would you have just anyone teach RSE?” Schools are already stretched, and will need support to deliver RSE effectively. Dr Menon-Johansson stressed that schools should bring in outside, third sector support where needed to “ensure that the quality is there across the board for all young people.”
113.We heard persuasive arguments supporting a strong stance on participation. Speaking about calls to allow parents to withdraw children Professor Newton stated:
My tendency would be to resist [calls to allow patents to withdraw children], unless there are very good cultural or religious grounds … I urge whoever is making those decisions to allow as many children as possible to benefit from it.
… providing good, solid age-appropriate relationship education at a young age is essential for laying the foundations for sexual health and good decisions later in life.
I am not sure what the valid argument would be for a child not receiving education, if it was correctly provided. The public health arguments are overwhelmingly in favour of providing that sort of education for all children.
114.We were pleased to hear that the Minister said he is confident that parents will not be able to deprive their children of the sort of education they would need later in life to help them avoid STIs. The Minister gave a personal view regarding teaching trans and LGBT issues:
You bring up children to face the society that exists, not the society that you want to exist. Teachers have a statutory obligation to teach the facts, not to teach opinions around that or anything else, political or otherwise. I think that young people should be taught exactly what is out there in life and what they will face when they go out into the bigger wide world. If that includes trans, absolutely. That is my view.
115.The Local Government Association raised concern about what happens when young people leave school. The number of STI diagnoses in young people increase significantly after school leaving age, in the 20–24 age group: in 2015 there were 78,066 new STI diagnoses in 15 to 19-year olds, compared to 141,060 in 20 to 24-year olds. Witnesses told us that there should be a consistency of approach when you leave school, and that young people need to know where to go next, and what that will look like. Ian Green argued:
Everybody, regardless of age, needs good, up-to-date sexual health information. It is the responsibility of all of us to provide that.
116.Prevention is a vital aspect of the sexual health agenda, particularly in the face of concerning behavioural trends that are leading to poor sexual health outcomes. Lamentably, investment and practice does not reflect the importance of prevention.
117.Prevention—activities that encourage healthy behaviours and changes that reduce the risk of poor sexual health outcomes—must be prioritised and adequately funded. Prevention is—or should be—an integral part of all sexual health provision, and the new national quality standards should therefore include preventative interventions within all aspects of sexual health.
118.Good sexual health starts with good Relationships and Sex Education (RSE). The Government’s new plans for RSE present an opportunity to correct a longstanding inadequacy, and to lay the foundations for young people to make intelligent, informed sexual health decisions throughout their lives.
119.The Government must take a strong line on participation in Relationships and Sex Education (RSE). Public health arguments are overwhelmingly in favour of ensuring that all children have appropriate RSE.
124 Annex 1
125 Annex 1
129 The King’s Fund,
130 The King’s Fund ()
131 Annex 2
133 Annex 2
139 Annex 1
147 Local Government Association ()
Published: 2 June 2019