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Sexual behaviour

Health and Social Behaviour: The Effects on Health of Sexual behaviour and Combating the Issue

Introduction

Sexual health is defined by the WHO as

  • Enjoyment of sexual relation without exploitation, oppression or abuse.
  • Safe pregnancy and childbirth, and avoidance of unintended pregnancies.
  • Absence and avoidance of sexually transmitted infections, including HIV.

Unhealthy sexual behaviour can lead to deviance from any of these three points.

Epidemiology

There is a clear relationship between sexual ill health, poverty and social exclusion.  There is also an unequal impact of STI infection on gay men and certain minority ethnic groups.

There have been large increases in many STIs in the last 10 years including Chlamydia (up 300%), gonorrhoeas (up 200%) and HIV (up 300%).  Since 1990, people are having sex for the first time at a younger age, a greater proportion of people
have multiple partners, and a greater proportion of men report having had a same sex partner.

As many symptoms are asymptomatic, and many cases don’t present due to stigma, the infection statistics are likely to be just the tip of the iceberg.  Co-infections are often common, and an infection with an STI makes transmission of HIV
easier.

The most common conditions in England are now Chlamydia, non-specific urethritis, and wart virus infections.  The number of visits to the GUM clinic doubled between the early 90s and 2000s.  Diagnoses of Chlamydia doubled in the 1990s,
particularly in the under 20s.  There have been recent outbreaks of syphilis.

Newly diagnosed HIV infections are increasing, especially in the migrant population.

Health Effects of Sexual Behaviour

Consequences of poor sexual health are complex and poor sexual health can have many effects on an individual as well as a relationship.

Unintended pregnancies

Unintended pregnancies can lead to poor education and lack of social and economic opportunities for teenage mothers.

STIs, including HIV

STIs are often asymptomatic and can therefore lead to further transmission. 

The Human Immunodeficiency Virus (HIV) attacks the body's immune system, therefore becoming more susceptible to opportunistic infections.  HIV has a long asymptomatic period that can vary between a few years and more than 10 years.  This
means that people often do not realise that they are infected and this can increase transmission rates.

Hepatitis

Hepatitis B is spread via sexual contact and contact with body fluids.  Infection with hepatitis B can be asymptomatic meaning that the disease may be transmitted unknowingly because individuals are unaware that they are infected.

Hepatitis C is primarily transmitted through coming into contact with the blood of a carrier of the virus.  Although sexual transmission rates are lower than for Hepatitis B or HIV, sexual contact is a risk factor.

Cervical and other genital cancers

The most significant risk factor for cervical cancer is the human papilloma virus, which is a sexual transmitted virus. The greater number of sexual partners a woman has without the use of condoms, the greater her risk of coming into contact with
this virus and of later developing cervical cancer.

Recurrent genital herpes

Genital herpes is a common virus infection caused by herpes simplex virus.  Genital herpes infection occurs through exposure of the genitals to the virus from a partner with active herpes (through either genital or oral contact). Antibodies
produced by the body to fight the infection mean that recurrent symptoms are milder than the first episode.

Bacterial vaginosis and early delivery

Bacterial vaginosis is a common condition of the vagina caused by an overgrowth of various bacteria (germs).  It is not sexually transmitted, and can affect women who do not have sex.  Untreated bacterial vaginosis during pregnancy can
increase the risk of early labour, miscarriage, and infection of the uterus (womb) after childbirth.

Chlamydia

Chlamydia can lead to pelvic inflammatory disease, leading to infertility. As Chlamydia is asymptomatic, it is often left undiagnosed and untreated for some time, which can then mean that infertility is a real risk.

Impact on relationships

STIs can have an affect on sexual health within a relationship.  Sexual intercourse can become painful or uncomfortable, as well as there being a risk of transmission of the STI.  It can also trigger a lack of trust due to confusion of
where the infection came from.

If a partner is not informed of an infection by their infected partner, this can lead to unknown transmission of infection, potential legal implications, and a lack of trust within the relationship.

Stigma

As well as the immediate implications of the infection on the individual, and discomfort, STIs can have other effects such as stigma.  Stigma against STIs, particularly HIV, can prevent people from seeking testing for the infection, or from
informing future partners of the infection, both of which can lead to further transmission of the infection.

Psychological consequences

Poor sexual health can also mean psychological consequences, for example through coercion and abuse.

Combating Sexual Behaviour Using a Wide Range of Approaches (including health service interventions and broader cultural interventions)

Government policy and recommendations

The Department of Health published its National Strategy for Sexual Health and HIV in 2001.  This was the first national strategy for sexual health, and there have not been additions to this or further national strategy since this.

In 2007, NICE published guidance on the prevention of sexually transmitted infections and under 18 conceptions.

The National Survey of Sexual Attitudes and Lifestyle (NATSSAL) was the first national survey or sexual behaviour in the UK, conducted in 1990/91 and then repeated with some modifications in 1999/2000 (NATSSAL II).   Monitoring sexual
behaviour should play an important role in sexual health service planning.

Abortion is legal in Great Britain under the Abortion Act 1967, as amended. 

Interventions

The Department of Health’s 2001 National Strategy for Sexual Health and HIV proposed:

  • Providing clear information so people can take informed decisions about preventing STIs including HIV.
  • Ensuring sound evidence base for effective local prevention.
  • Setting targets and reducing the number of newly acquired HIV infections.
  • Developing managed networks for HIV and sexual health services, having a broader role in the primary care setting and collaborating to plan services jointly. 
  • Evaluating the benefits of a more integrated sexual health service, including pilots of one-stop clinics, youth services, and primary care teams with a special interest in sexual health.
  • Beginning a programme of Chlamydia screening for targeted groups (this is now established).
  • Open access GUM services, improving access for urgent appointments so that patients are seen within 48 hours.
  • Having a range of contraceptive services for those that need them.
  • Addressing disparities in abortion services.
  • Increasing offers of HIV testing, targeting to reduce the number of undiagnosed infections leading to earlier treatment and limiting further transmission.
  • Increasing offer of hepatitis B vaccine.
  • Setting standards for treatment of STIs and for treatment, support and social care of people living with HIV.
  • Setting priorities for future research to improve evidence base of good practice in sexual health and HIV.
  • Addressing the training and development needs of the workforce across sexual health and HIV services.

September 2008 sees the introduction of routine HPV vaccination for all girls aged 12-13 as part of the national immunisation programme.  This will help protect against cervical cancer.  Human papilloma virus (HPV) is the name for a
family of viruses.  Around 40 types of HPV infection can affect the genital area, an infection with some types of HPV can cause abnormal tissue growth and other changes to cells, which can lead to cervical cancer, or genital warts.

Improving access to contraceptive services and full range of methods is one of the key aims of the Government’s White Paper - Choosing Health: Making healthier choices easier.  Changes in recent years include prescribing the pill to girls
below the age of consent, and free contraceptive services.  The availability and cultural attitude to condoms has changed, increasing usage and therefore having a preventive effect on STI transmission.  Ease of service should be accompanied
by action to improve knowledge and promote healthy sexual behaviour.

The 2007 NICE guidance on the prevention of sexually transmitted infections and under 18 conceptions recommends that:

  • Health professionals should identify individuals at high risk of contracting STIs using their sexual history. 
  • Health professionals should have one-to-one structured discussions with individuals at high risk of STIs (if trained in sexual health) or arrange for these discussions to take place with a trained practitioner. 
  • Patients with an STI should be helped to get their partners tested and treated when necessary.
  • Midwives and health visitors should regularly visit vulnerable women aged under 18 who are pregnant or who are already mothers and discuss with them and their partner how to prevent or get tested for STIs and how to prevent unwanted
    pregnancies.

The Department of Health has developed an Effective Sexual Health Promotion Toolkit in response to the first national strategy for sexual health and HIV.  The implementation action plan was published by the Department of Health in June 2002.
It represents a wide range of interests and views within sexual health and health promotion and HIV prevention.

In 2005, the Department of Health set to improve further the sexual health services by publishing recommended standards.  These aim to give guidance to healthcare professionals working in the field as well as give people an idea of the level
of sexual health services they should expect. The standards include:

  • A programme of sexual health promotion to help reduce the risk of STIs and unwanted pregnancy.
  • Measures to improve detection of sexual health need, including Chlamydia screening.
  • Improving access to, and information on service provision.
  • Speedy detection and management of STIs.
  • Prompt access to contraceptive advice and provision.
  • Services working together to increase choice for their users.

Stigma is an important issue in sexual health.  The need to tackle the stigma associated with HIV was identified in the National Strategy for Sexual Health and HIV in 2001, and a commitment to publish an HIV stigma action plan was made in the
strategy's implementation action plan in 2002.  The National AIDS Trust undertook the 'Are YOU HIV prejudiced?' campaign, and more recently the development of resources for health workers and employers.

References

  • The Department of Health website Sexual health pages:
    http://www.dh.gov.uk/en/Publichealth Accessed August 2008-08-17
  • The National Institute for Health and Clinical Excellence.  Public health guidance on prevention of sexually transmitted infections and under 18 conceptions.  February 2007
  • The Department of Health.  The national strategy for sexual health and HIV.  2001.

© Sally Cartwright 2008