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Sexual Health Ill
Factors that contribute to the poor sexual health of Britain’s youth
Problems with sexual health affect all sections of society including all age groups. Sexual ill health disproportionately affects vulnerable groups such as young people between the ages of 16 and 25, ethnic minority groups and those affected by poverty and social exclusion. (World Health Organization, 2004) Sexual health refers to the issues which impact on sexual function and reproduction. Such issues include a physical, mental and emotional factors which may have a varying amount of impact on the individual, leading to disorders affecting physical, mental or emotional wellbeing. (Dehne & Riedner, 2005; World Health Organization, 2004)
Sexual ill-health may thus be defined as the consequence of such issues in terms of their effect(s) on the wellbeing of an individual. Serious complications with sexual health particularly affect women and gay men and there are disproportionate geographical inequalities in the rate and degree of sexual ill health and inequalities in sexual health service provision in the UK. For example, the results of a study focusing on syphilis reported that there have been increasingly high rates of disease transmission over the last five years in Britain, as well as in several parts of Western Europe. The report also stated that the most alarmingly high rates of syphilis prevalence have been seen in the wealthiest cities of England such as London. (NHS, 2008)
According to the Independent Advisory Group on Sexual Health and HIV, (2007) there are serious inequalities in sexual health service provision in the UK and the groups most likely to suffer because of this are identified as young people who are considering becoming sexually active, men who have sex with men and black and minority communities. The possible reasons for such inequalities are discussed further in detail, along with the importance of these issues being reprimanded and their effects reduced. The major causes of morbidity and mortality among young people are road traffic accidents, suicide, drug use (including cigarettes, cigars and alcohol) and sexual and reproductive ill health. (World Health Organization, 2004) The consequences of poor sexual health have important implications for all individuals as well as society as a whole.
Unwanted pregnancies may have a long lasting impact on quality of both the mother’s and the child’s life. Since the International Conference on Population and Development in Cairo in 1994, recognition of young people’s specific sexual and reproductive health needs has gradually increased. Attempts to date to promote the sexual health of young people have tended to focus on prevention, education and counseling for those who are not yet sexually active, while the provision of health services to those who have already engaged in unprotected sexual activity and faced the consequences, including pregnancy, STIs or sexual violence has lagged behind. (Dehne & Riedner, 2005)
The identification of this matter has lead to a shift in focus on sexual health and motivation towards the promotion of services available to people in the UK. In 2004, the World Health Organization (WHO) launched an activity to promote sexual health and a positive view of sexuality for young women and men as issues to be addressed separately from the wider subject of reproductive health. In the past, but particularly since the 1994 International Conference on Population and Development, sexual health was defined as an incorporation of the subject of reproductive health. The launch of this activity was the direct result of the emergence of the pandemic of human immunodeficiency virus (HIV) infection, increasing rates of sexually transmitted infections (STIs) and an increasing awareness of the importance of gender-related violence and sexual dysfunction concerns. Such changes in sexual health have emphasized the need for more explicit focus on issues related to sexuality and the direct implications for general health and wellbeing. (World Health Organization, 2004)
Despite efforts made to strategize improvements to sexual health policies in recent years, data shows that numbers of STIs in Britain continue to grow at a problematic rate and cost the National Health Service dearly in prevention and treatment methods. Statistics regarding sexual health in Wales published in Better Health – Better Wales in 1998 (Welsh Office, 1998a) highlighted trepidation regarding the high rates of teenage pregnancies and STIs in the region. In response to these concerns, the Welsh Assembly’s publication Better Health – Better Wales Strategic Framework (Welsh Office, 1998b) included a commitment to the people for the betterment of sexual health and to take account of and successfully deal with the inequalities surrounding sexual health concerns.
Strategies were also directed towards the improvement of emotional support for those involved in sexual relationships, as well as support for the education of sex in schools. In addition to the responsibility assumed by England and Wales to try to tackle sexual health concerns, Scotland also released a response to growing rates of abortions, unwanted pregnancies and ill health in the form of a Sexual Health and Relationships Strategy, (Scottish Executive, 2005) which aimed to challenge the government for better services by promoting a strategy based firmly on “self-respect, respect for others and strong relationships” (Scottish Executive, 2005). In short, action was directed towards the avoidance of contracting and spreading sexually transmitted infections and towards the avoidance of unwanted pregnancies by promoting the individual’s responsibility for themselves and others through specific educative measures.
Despite the efforts made by the three governing bodies in the UK to act on sexual health concerns, there is evidence indicating that some years on, we are still seeing problematic levels of unwanted pregnancies and sexually transmitted infections in young people and a systematic review of the literature seems to suggest limited knowledge of sexual health associated with young people. (Wellings et al., 2002; NHS 2007)
A thorough study of the literature concerning sexual health in young people reveals that there are four main areas of consideration for this matter. These include the level of knowledge of sexual health to young people, consequences of sexual ill health, factors influencing the use and non-use of condoms and intervention(s) for the promotion of condom use. We therefore now take a closer look at the condition of sexual health in young people in the UK in detail to identify the specific areas where intervention can promote better sexual health in order to reduce the prevalence of sexually transmitted infections in this group of people and we also give further consideration to the consequences of STIs and the factors affecting the use of condoms.
According to a study performed in 2001, when compared with several countries, Britain has a relatively low rate of HIV and other sexually transmitted infections, which reflects the historical investment in establishing the Genito-urinary Medicine (GUM) clinic. However, data from 2001 showed evidence that there is heterogeneity in the population distribution of STIs which are diagnosed, and the wide distribution of undiagnosed Chlamydia showed that the strategy adopted in Britain in response to the International Conference on Population and Development in 1994 failed to relieve the problem of ill sexual health by 2001. (Fenton et al., 2001) Looking a little later on to over a decade since the international conference, we learn that the number of newly diagnosed sexually transmitted infections continued to rise in 2006 indicating that sexual health still required careful attention at this time. Furthermore, the same study showing that sexually transmitted infections were still on the rise in 2006 also gave overwhelming evidence that the highest rate of STI diagnoses continued to be among young people between the age of 16 and 24 years and that genital herpes in particular sharply rose by 16% from 2005 to 2006 in teenage women. (Hughes et al., 2006)
There is much further evidence in the literature to show that young people are most at risk from sexual health problems including notable statistics which show that Chlamydia affects one in ten sexually active young women and each year, numbers of cases rise by 9%. (Department of Health, 2003) There is thus, some significant evidence showing that sexual health in the UK continues to decline and any efforts being made to prevent such an increase in rate of infection are clearly neither sufficient nor effective. This effect on young women has changed little since 2003 and remains a cause for concern at the present time. (Department of Health, 2003; IAG, 2006/2007) Recognition of the problematic numbers of affected young people, particularly women lead to the implementation of a strategy designed to tackle ways of reducing teenage pregnancy and improving sexual health among vulnerable groups of young people.
This strategy ended in December 2006, yet there still remains concern regarding the health of young sexually active people supported by statistics documenting the behaviour of young people today. Sexually transmitted infections (STIs) among adolescents in particular, are of great concern to all those who work to improve the health status of human populations. Sexually transmitted infections are widely associated with stigmatization, denial and embarrassment among patients and health workers. Sexuality and associated health risks are still a major taboo in many societies and this may be especially true for young people between the ages of 16 and 25 years. While the young person’s rights and needs may be acknowledged in theory, the story is very different in practice and they are still confronted with many barriers when it comes to obtaining the practical support they need to avoid health concerns. According to Dehne and Riedner (2005) an indication of their “unmet needs” is the worldwide scarcity of services available for young people, in particular, services related to the treatment of sexually transmitted infections. (Dehne & Riedner, 2005)
Significant data has shown that almost 30% of young men and nearly 26% of young women report having sexual intercourse before the age of 16 and by the age of 20, the majority of young people have had sex. (Brook, 2001) The high number of young people having sex at an early age means that this group has a high risk of transmitting sexually transmitted infections and indeed of becoming unintentionally pregnant. Evidence supporting this is found in a study by Marston and King (2006), who found that nearly 50% of new HIV infections worldwide are found in young people between the age of 15 and 24 years.
Further evidence suggests that this figure is nearer 60%. (Dehne & Riedner, 2001) Thus there is some significant room for attention towards this group to change sexual behaviour to deal with a pandemic such as this. (Marston & King, 2006) The high risk of STI transmission, as well as the increased chance of encountering other sexual health problems in young people has led to the motivation for this study and we are persuaded that there are inextricable forces acting on young people, which are causing them to suffer unnecessarily. We offer a thorough investigation into the causes of various sexually transmitted infections and ill-health epidemics in the UK in the hope of identifying the main voids in bureaucratic procedure towards the paradox of sexual health in young people.
Research on sexual health in young people seems to suggest that knowledge of the causes and consequences of sexually transmitted infections as well as the consequences of sex in general to young people maybe limited (Wellings et al., 2001; NHS, 2007) and it is likely that this lack of knowledge is a large contributing factor in the high prevalence of STIs in young people in the UK. The fact that ‘young’ signifies only very few years of experience as a sexually mature adult is also, albeit an obvious one, a reason for the high parameters of sexual health problems in this group of people and another why they might have unsafe sex.
Although sexual education begins at a young age (usually 11 years old and lasts until 16 years), a report by Lester Coleman (2007) on the preferences towards sexual education by a multi-cultural group of individuals revealed that despite the different religions of children in schools in Britain today, there are a number of similarities across practising religious groups which include the preference for more information regarding STIs and how to increase sex satisfaction. Thus, there is evidence to suggest that there is at least some room here for improvement in the educational methods used for the prevention of sexual health problems through knowledge acquirement. (Coleman, 2007) Furthermore, according to Jackson and Plant (1997), despite the improvement in the knowledge of sexual health matters to young people shown in the early 1990s, young people lack knowledge about how to use sexual health services provided and they are also unsure about the issue confidentiality to their parents and general practitioners if they were to attend a surgery or family planning clinic for advice and/or treatment.
This revealing might help to explain not only the high numbers of STIs and unwanted pregnancies in young people, but also the lack of knowledge young people have of matters relating to sexual health. Also, the failure of most young people to recall the anonymity of sexual health services, as found by Jackson and Plant (1997), clearly shows the lack of communication between educators and students over these matters, or perhaps more accurately, the failures of sexual health educators to effectively inform young people of all of the important elements relating to advice and treatment of sexual health problems. If proper communication was involved between informer and ‘informee’ and feedback was necessitated, it should have been obvious that anonymity would be a major concern to young people requiring treatment or advise, especially those who are below the legal age to be having sex, or indeed those with cultural backgrounds who do not allow sexual activity at their current age.
Campaigns over the recent years targeting young people have encouraged safe sex through promoting condom use and the avoidance of penetration. Efforts have included dispensing free condoms and providing information through schools. However, even in instances where condoms have been widely available and education of sexual health problems has been great, such campaigns have not been desirably successful. It has been demonstrated that there are powerful cultural and social forces in play, which appear to strongly influence sexual behaviour. This discovery might help to explain why free dispensation of condoms is not working as well as expected to reduce rates of sexually transmitted infections and unwanted pregnancies. It might also help to explain why some of the HIV programmes have also not been effective. (Coleman, 2007)
Consequences of sexual ill health
The physical symptoms of sexually transmitted infections are varied but there are a few generalizations which include itching, redness and soreness around male and female genital parts. The most common STI to date is Chlamydia, which is caused by the bacterium Chlamydia trachomatis. In women the infection often presents no symptoms which makes diagnosis without examination difficult in many cases and there may also be non-specific symptoms such as cystitis, an altered vaginal discharge or abdominal pain. If left untreated, the female reproductive organs can be irreparably damaged and can cause sterility. (Centre for Disease Control and Prevention, 2007)
Men may experience pain whilst urinating, develop a discharge from their penis and have inflammation of the urethra or testes. (NHS, 2007) Other sexually transmitted diseases which are common effects of unprotected sex and which have various physical symptoms leading to damage of the reproductive tract if left untreated are: genital warts; genital herpes; gonorrhoea; syphilis; HIV; trichomoniasis; pubic lice; scabies; thrush; and non-specific urethritis. Emotionally, the occurrence of an STI can cause problems for the patient related to a feeling of shame and of being ‘dirty’, especially in the event that a patient must make contact with previous partners to inform them of their infection. (NHS, 2007)
There has been an increase in the interest in the sexual behaviour of young people in the second half of the 20th century, which has been fuelled partly by a concern for their sexual wellbeing. In the 1960s and 1970s, nervousness surrounding the rates of contraception among young unmarried people provided the impetus to much research, but a decade later, the focus shifted to the risk of HIV transmission among young people. By the end of the 20th century, the UK had the highest rate of teenage births in Western Europe and an increasing rate of most sexually transmitted infections among young people. Attention has now focused on risk behaviour in the context of both sexually transmitted infections and unplanned pregnancies in young people. (Wellings et al., 2001) and it is estimated that the prevention of unintended pregnancies saves the NHS over £2.5bn a year (Kinghorn, 2001; The Department of Health, 2006).
The average cost of contraception failure is estimated at £1500 per person, which is inclusive of the costs of abortion, miscarriage, ectopic and live births. (Department of Health, 2006) Sexually transmitted infections (STIs) are associated with serious maternal and neonatal morbidity, infertility, anogenital cancer and transmission of human immunodeficiency virus (HIV). The average lifetime treatment cost for each HIV positive individual was estimated to be between £195,000 and £200,000 (Bernard, 2006; Bartlett, 2007).
At £580 million a year, HIV imposes a significant burden on healthcare resources. As well as the high cost of care and treatment, HIV is associated with extreme morbidity, significant mortality and a significantly reduced life. It has been determined that preventing the onward infection of just one case of HIV saves the NHS around £0.5 million in health care costs and individual health gains. Figures at the end of 2006 indicated that the direct costs of treating other STIs cost the health service approximately £165 million a year and if the cost of treating sequelae were to be included, this would increase exponentially.
Chlamydia, for example, often produces no symptoms, but if left untreated it can lead to pelvic inflammatory disease, infertility and ectopic pregnancy, which impose high costs on individuals and on the National Health Service. (The Department of Health, 2006) When fertility treatment such as in vitro fertilization (IVF) becomes necessary due to fertility problems associated with STIs, there is no funding available for patients and those people affected much shell out thousands of pounds for such procedures. The NHS offers no help for any person requiring fertility treatment, despite evidence seeming to point to the failure of government bodies responsible for the promotion of sexual health to effectively diagnose and treat people with sexual health issues. (NHS, 2007)
Gender is an important issue in STI prevention and care and there are many scientists who believe that gender is the largest role being played in the prevailing increase in sexually transmitted infection rates. (Marston and King, 2006; Coleman, 2007) Gender-based inequalities put girls and young women at an increased risk of becoming infected with a sexually transmitted infection and these inequalities also affect these women’s access to prevention and care services.
In addressing these inequalities, we must try to best consider the different requirements and also constraints of young women and young men when we are designing interventions to tackle sexual ill health. (Marston and King, 2006)
According to a study by Marston and King (2006), sexual partners influence the behaviour of young individuals in many ways and young people are known to assess potential sexual partners as “clean” or “unclean”. Furthermore, there appears to be certain stigmas associated with condoms, such as a lack of trust, and societal norms prevent the lucid communication about sex. (Marston and King, 2006) From a biological perspective, hormonal changes in young men and women which are likely at various times between the age of 16 and 25 years will have a profound affect on the decision-making ability of the individual; especially in younger years and this is likely to be a plausible explanation for certain acts considered by individuals as ‘mistakes’. (Verhoeven, 2003)
STIs such as chlamydia, syphilis and gonorrhoea are passed from one individual to another through intimate sexual contact either during vaginal, anal or oral intercourse with an infected partner. (NHS, 2007) The timing and conditions of sexual initiation are of substantial interest in the context of public health. Early age at first intercourse is associated with subsequent sexual health status. Following the steep decrease of age at first intercourse among women up to and incuding the 1970s, in many countries there is evidence of subsequent stabilisation. In several European countries, this stabilisation occurred in the 1980s. In Britain however, heterosexual intercourse continued to occur at earlier stages throughout the 1980s. Factors associated with early age at first intercourse are well documented and include early school leaving age, early menarche, family disruption and a disadvantaged and poor education. A study by Wellings et al., reported a decline in age at first intercourse in successive age-groups and significant increase in condom use among the youngest age cohort, born between 1971 and 1976.
Several important trends have been identified in this data from the National Survey of Sexual Attitudes and Lifestyles (Natsal) in 2000. There seems to have been a stabilisation of the proportion of people having first heterosexual intercourse before the age of 16 years among women, as well as a continuation of the increase in condom use and in the decrease in the proportion not using contraceptive methods at first intercourse. There also has been identified an increase in the importance of school in the sexual education of the young, in particular men.
Despite the strong trends identified in this data, the author is right to point out that the data is based on alleged behaviour and thus is susceptible to biases associated with recall and veracity. With time, it is pointed out, early experiences may be recast or forgotten although the ability to recall any event is dependent on the time passed since the event’s occurrence, and also on its salience. According to the results of experiments, less than 1% of respondents were unable to remember, with accuracy, their age at first intercourse. This result demonstrates that first intercourse is fairly non-memorable for individuals and there may be implications here into the general lack of responsibility taken with regards to contraception at this time.
Further, if we look at the decade of the 1990s as a whole, a higher proportion of young women in Britain reported heterosexual intercourse before the age of 16 years when compared with the previous decade and the median age at first intercourse was also shown to be lower for men than women. Looking within the 1990s however, there are some tentative and possibly ambiguous signs in the data that the trend showing increasingly earlier heterosexual intercourse may have in fact stabilised for women.
Furthermore, there is evidence of increasing adoption of risk reduction practices. For only a minority of young people is first intercourse unprotected against infection and conception. The data in the study shows a remarkable rise in condom use in Britain, despite the predictions that a weaker impact of AIDS-linked safer sex messages might have brought about complacency. 25% of young women in this study were already using oral contraception at first intercourse but with respect to the circumstances of first intercourse, the evidence is less positive. Despite the agreement in the behaviour of men and women at particular ages at which first intercourse occurs, there remain gender differences in the experience of the event such as those described above. The proportion of those young people who are sexually proficient according to the criteria which was used, has increased over time; particularly among men. Further evidence reveals that women are two times as likely as men to regret their first experience of intercourse and three times as likely to report being the less willing partner. These findings have also been supported by Wight et al., 2000 and Dickenson et al., 1998.
26% of women aged between 16 and 19 in this study were found to have had intercourse by 16 years, which is the legal age to have sex in the UK. (NHS, 2007) There is evidence to suggest that a focus on absolute age at first intercourse may not take into account variations in individual development and social norms. Although sexual competence decreases substantially with age at intercourse, more than 30% of young women for whom first intercourse occurred at age 15 years were sexually competent, and more than a 30% of those aged between18 and 24 years at the time were not.
The report shows early age first intercourse to be significantly associated with early pregnancy but not experience of sexually transmitted infection. Although early menarche is independently associated with early age first intercourse and with early motherhood, importantly, in terms of the potential for enhancing sexual health, the risk behaviours and outcomes described are also associated with cultural and social factors.
Of these, the association is stronger for education than for family background. Young people who leave school later, with qualifications, are less likely to have early intercourse, more likely to use contraception at first sex, be sexually competent and, for women, less likely to become pregnant if they have sex. Family disruption and lower parental socioeconomic status are also associated with early sexual experience and pregnancy when younger than 18 years, but the effect is weaker. (Wellings et al., 2001)
The absence of a significant association between educational level and abortion, compared with the strong association with motherhood at younger than 18 years, supports the premise that educational prospects influence the outcome of pregnancy. We do not know to what extent poor educational aspirations themselves lead to early sexual experience and motherhood and the extent to which having a child early in life thwarts academic expectations. Nevertheless, this data identifies a vulnerable group of women in public health terms; 29% of sexually active young women in this study who left school at 16 years with no qualifications had a child at age 17 or younger.
From the viewpoint of prevention, there is much that is positive in this data: the sustained increase in risk reduction at early sexual experience; the increasing prominence of the school in the sexual education of the young and the fact that the variables which emerge as most strongly associated with reducing risk are those which are amenable to intervention. Of interest too, with respect to the possible stabilisation of the trend towards intercourse is the evidence from the USA of a reduction in the teenage pregnancy rate following their earlier experience of a similar trend. The strong association between educational attainment and early motherhood also supports the British government’s strategy to marshal the efforts of ministries concerned not only with health but also with education and social services, in a bid to reduce the incidence and adverse outcomes of early teenage pregnancy.
Marston and King, in their 2006 study found that there are penalties and rewards encountered for sex which may well affect the rate of STI transmission in the UK. According to these two authors, social rewards and penalties influence sexual behaviour. Adhering to gender expectations and formalities has been seen to raise social status. For women, complying with stereotypes can secure an exclusive relationship with a man, and for men, complying can lead to many partners. (Nyanzi et al., 2001)
While pregnancy outside marriage can be stigmatising, for some women pregnancy can be a way out of the parental home. Young people may behave in particular ways through fear of being caught in the act. Sex can also be a way to obtain money and gifts from boyfriends:, which is particularly well described for sub-Saharan Africans, although this behaviour is not exclusive to this part of the world. (Nyanzu et al., 2001) It is believed that the relationship between individual enthusiasm and societal expectations is a complex one as some behaviour considered taboo can become desirable for that very reason. (Marston and King, 2006)
Reputations are crucial for social control of sexual behaviour according to scientists. Marston and King, 2006; Stephenson et al., 1993) Reputations are linked to displays of chastity for women, or heterosexual activity for men. Social isolation can result from activity leading to being branded “queer” or a “slut”, and in some cases, such brands can result in worse cases such as gang rape and murder. (Wood et al., 1998) A woman’s reputation can be damaged by having “many”, or more than one partners according to Marston and King (2006) and even the mentioning of sex can risk implying sexual experience and lead to a damaged reputation.
Although it has been found that communication across generations about sex is rare, family members may for instance prevent young people socialising with members of the opposite sex to protect the reputation o the family. (Hennick et al., 1992) Young men’s reputations can suffer if they are not seen to push for sexual access and numerous female partners according to some scientists, (Varga, 1997; Harrision et al., 2001) thus, the display of heterosexual activity can be important. It is common that some groups of men visit brothels together in Southeast Asia and young men proudly report sexual experiences to their peers. (Varga, 1997) Furthermore, there is often a stigma attached to not having penetrative sex, and indeed not being able to do so. Young men not having sex with their girlfriends may be accused of being “gay”.
According to a study in Britain by Hughes et al., (2007) new STI diagnoses increased between 2005 and 2006 by an overall 2% whilst diagnoses of other STIs increased by 3% over the year. Looking further back, there has been an increase in new STI diagnoses of 63% between 1997 and 2006 and an 84% increase of existing STIs over the same time period. According to these figures, strategies in place between these times were not working effectively to reduce the incidence of STIs in young people.
Between 2005 and 2006, services available to the public in the form of clinics and sexual health screening and HIV tests were increased by 6% thus making them more readily available. The number of HIV tests taken was said to have risen by 12% over that year and the number of sexual health screens rose by 9%. (Hughes et al., 2007) Thus, despite the increase in the services available to the public in the early 2000s, STI incidence continued to rise. There is therefore clearly a huge requirement for the betterment of these services to allow a significant reduction in new and existing STI diagnosis.
Presently, services available to young people with sexual health concerns include genitourinary medicine (GUM) clinics, which are usually situated in separate Primary Care Trust departments at hospitals around the country. The NHS also provides a number of drop-in centres in Britain where appointments are not necessary. They also work on an anonymous basis, which avoids causing embarrassment to the patient. On-site testing facilities enable a fast diagnosis and many GUM clinics offer a ‘while you wait’ diagnosis so that treatment can commence as soon as possible. (NHS, 2007b) Strategies put in place by the British government, for the people of England, Wales and Scotland have focused on access to GUM clinics by providing a 48-hour appointment access service to enable people to be seen by a clinician within 2 days of speaking to someone in the Primary Care Trust service. (Department of Health, 2007; Scottish Executive, 2007; Welsh Assembly, 1998a)
There has been some success with this activity to date and the Department of Health aims to sustain this level of improvement and build on it after 2008. (Department of Health, 2007) Whilst there has been success with this activity, the high numbers of STIs in young people must be accounted for in some way. It is evident that despite the availability of appointments at GUM clinics, it may be difficult for school goers to get an appointment that they can attend due to schooling activities in the day, or indeed in evenings. It is also true that any appointments provided out of school hours are likely to get booked very quickly due to demand. It remains to be seen how such effects are to be negated. Although there is an NHS Out of Hours service available for all health problems including those of a sexual nature, there is little documentation regarding this facility and little in the way of advertisements to promote it. Perhaps if more young people knew that there was a nearby service offering advice and treatment for sexual health concerns out of normal hours, more people could be diagnosed and treated (NHS, 2007)
In a further study by Marston and King (2006), several themes were identified as being related to sexual behaviour in young people. Research showed that it is not only sexual behaviour which is strongly shaped by social forces, but also those forces are surprisingly similar in different settings with variations of the extent to which each theme is present rather than of kinds of themes. For example, women’s sexual freedom is universally restricted compared with men’s. The exact nature of what is deemed inappropriate and the penalties for transgression- from verbal censure to ‘honour killings’, a practice in which a family member kills a female relative as punishment for sexual behaviour considered to have brought dishonour to the family-will vary both with and between societies.
There is evidence to show that young people subjectively assess the risks from sexual partners on the basis of whether they are “clean” or “unclean”. Furthermore, studies repeatedly show that young people assess the disease risk of a potential partner by how well they know their partner socially, their partner’s appearance, or other unreliable indicators. (Kinghorn, 2001)
A variety of social pressures might mean that women do not want to talk about sex or acknowledge any sexual desires, particularly in the early stages of the relationship. (Varga 1997) It has been shown that young people often avoid communicating openly to partners about sex, and thus encounter many ambiguities. (Maston and King, 2006; Harrison et al., 2001; Hennick et al., 1992) For example, women avoid saying “yes” to sexual in case they are viewed as seeming inappropriately willing. This makes “no” difficult to interpret. As a result, genuine refusal under these circumstances can be difficult to determine.
Further, young people may avoid discussing sex in case that leads to loss-of-face or hurting of others’ feelings, or indeed damage to their reputation. Because of this, safe sex is difficult to plan, as the possibility of intercourse is not acknowledged and if this is the case, contraception is unlikely to be a topic of conversation. (Cragg et al., 1993) Young people could also be reluctant to discuss condom use in case it is seen as equivalent to proposing or agreeing to sex. According to an experiment performed by Mitchell and Wellings (2002), one man in the UK recounted that producing a condom creates the problem that you are assuming that you are going to have sex with someone but you don’t know whether the partner even want to have sex with you. Avoiding talking about condoms keeps the option of refusing intercourse open. (Mitchell and Wellings, 2002)
Stereotypes associated with gender are vital to determining social expectations and behaviour. All the societies which have been studied reveal strikingly similar expectations of men’s and women’s behaviour. Men are expected to be highly heterosexually active and women not so, in fact, chaste; still having virginity at marriage. (Holland et al., 2000)
Sex often has high social value. (Holland et al., 1998) Vaginal penetration is perceived to be important in determining masculinity and signifies the transition from boyhood to manhood. Men are expected to look for physical pleasure but women desiring sex can be detrimentally branded. (Schitter and Madrigal, 2000; Wood et al., 1998) Where it is expected that romantic love will precede marriage, sex for young women must be linked to romance and they are expected to be ‘“swept off their feet” into sexual intercourse’ (Schitter and Madrigal, 2000). On the other hand, men may scheme and plot in order to obtain the pleasure of sex. In spite of the stigmatising effect for women in carrying or using contraception, women, not men, are generally considered responsible for preventing pregnancy. (McKernon, 1996)
A further theme which has been identified as playing a part of the sexual decision-making in young people is the strong influence sexual partners have on all types of behaviour in general. The nature of the partner and the partnership influences not just whether a young person uses a condom, but all sexual behaviour in general. (Foreman, 2003; Kinghorn, 2001) Individuals might see sex as something that could strengthen a relationship, or as a way to please a partner. Pregnancy can even be seen as a way to keep hold of a boyfriend. (Rasche et al., 2000) Some young people live in fear of physical violence if they do not consent to sex. (Varga, 1997) Violence in relationships against women is sometimes viewed as normal or as being the fault of the victim. (Hird, 2000) According to Marston and King (2006) girls in South Africa were told by friends to keep silent about coercion and violence by boyfriends. If being a woman is viewed to require a stable partnership with a man, failed partnerships can damage a woman’s social position. (Marston and King, 2006)
It has been identified that people will readily use condoms to protect against disease with ‘risky’ partners. For instance, in Shanghai, men seemed to feel they could distinguish between women who were likely to be ‘clean’ and thus, disease-free and ‘unclean’ based on their behaviour and social position. Thus, young people who use condoms in short-term relationships might not use them in longer-term relationships. (Kinghorn, 2001)
Marston and King (2006) relay that such young people may use condoms with long-term partners to avoid pregnancy, which could be more of a concern to them in this position than disease. It has been shown that condoms may be very stigmatizing and signify a lack of trust. Carrying or buying condoms can affect a sexual experience for both men and women; it has been shown that doing so maybe undesirable for women, but sometimes desirable for men. (Holland, 1998) In a similar way, asking for condoms can imply inappropriate experience for women. (Marston and king, 2006) Young people also worry that asking their partner to use a condom implies that they think their partner has a disease, and therefore, intercourse without a condom can be seen as a sign of distrust. In parts of Africa for example, notably in South Africa, wanting to use a condom can be interpreted as a sign of carrying disease. (Swart-Kruger et al., 1997)
It is a worry to some men that they will be unable to achieve penetration and may even avoid using condoms use in case it causes loss of erection. (Varga, 1997) Effects of condoms such as these will play a large role in determining whether someone will be a condom user or not and thus have a significant affect on the prevalence of STIs and unwanted pregnancies in the UK.
Condoms are considered to be the only method of contraception to offer protection against both pregnancy and sexually transmitted infections. Because of this, condoms are a major priority in many sexual health improvement strategies. 50% of girls under the age of 16 years who were reported to be attending family planning clinics in 2000-2001 chose male condoms as their desired method of contraception. In addition, the proportion of people of all age groups using condoms reportedly rose from 6% in 1975 to 35% in 2001. (Stammers, 2002)
In a survey performed in 2001, it was found that only 40% of unmarried 18-59 year olds used condoms at last intercourse. Thus, the act of buying and carrying condoms is not directly proportional to their use. Reports suggested that even when sexual contact was of a casual nature, still only 62% of people used condoms. (Stammers, 2001) In a related study, it was found that of 8,500 American undergraduates, only 43% of students always used condoms, and 24% of people didn’t ever use them. Men with many partners reported the lowest condom use and those men who only had sex with other men were less likely to use condoms than those who had sex with women. (Smith, 1992)
With the rate of sexually transmitted infections in the UK soaring, the effectiveness of the condom is increasingly becoming questioned and the use of condoms has been compared to playing Russian roulette. (Smith, 1992; Stammers, 2001) Scientists in the field of sexual health are now asking the question of why the promotion of condoms is not making a large enough impact on sexual health statistics in most developing countries and whether or not we have the correct balance between the message that condoms prevent pregnancies and STIs and the message that partner reduction and selection is extremely important to sexual health. Furthermore, this begs the question of whether health care professionals have been co-conspirators in promulgating the idea that condoms make for safe sex. (Stammers, 2001)
In 1999, the rate of condom contraception method failure was 3%, with the failure rate for condoms being 14%. (Fu et al., 1999) Therefore, at least one in seven condom users became pregnant in this year. The failure rate of condoms varies greatly and according to Stammers (2001), depends more on the experience of legitimate condom use rather than the user's age. In a collective study using 4,600 condom attempts in monogamous couples, it was shown that the rate of condom breakage was only 0.4% and the corresponding condom failure rate was as low as 1%. (Haignere, 1999) Of these students, over 33% of heterosexuals reported that they delayed putting on condoms until after initial penetration, which helps to explain matters. (Haignere, 1999)
According to reports, approximately 80% of requests for the emergency pill arise from condom failure. This suggests that sole reliance on the use of condoms will not do much to reduce unwanted pregnancy rates, especially if young people are filled with a false sense of their effectiveness as this will result in more acts of intercourse taking place. (Wellings et al., 2001) This risk displacement is well recognized in the sexual health sector.
Reliance on the use of condoms leads to an increased frequency of sexual intercourse, whether with the same partner or different partners. Given the failure rate of 14%, combined with the failure to address changes in consequent sexual behaviour, the promotion of condom use may likely result in increased prevalence of STIs and unplanned pregnancies. (Stammers, 2001)
Protection provided for individual sex acts is not the only factor when dealing with the sexual health of a human population. If confidence in the safety of condoms indeed leads to increased rate of intercourse, the rate of acts of unprotected sex will increase. (Stammers, 2001)
Despite the reality of condoms being less safe than previously thought, they do provide protection against HIV and it is because of this there have been and continue to be many promotion strategies for condom use, especially those targeted at young people. However, the prevalence in of HIV in the UK in comparison to other STIs is low and it may perhaps be noted that at the time of the outbreak of HIV in the UK, there was much publicity regarding condoms in the prevention of the disease and this shift in focus may have caused people to forget about their use in preventing transmission of other STIs, which are more common in this country. The strong promotion of condom use and HIV prevention may thus have led to a general feeling that condoms are related to HIV only and this may have caused their use for protection against other STIs to be overlooked by many. Condoms also provide protection against gonorrhea and other STIs, but the success of protection against these other STIs, is less clear in the literature. (Wellings et al., 2001)
Condoms are known to reduce sensitivity during sexual behaviour and hinder spontaneous sex.
Overall, when we consider all of this information concerning condoms, we are shown reasons for the consistent condom use rates being very low. We then ask what an appropriate alternative is to the use of condoms for safe sex. In response, we suggest ‘saved sex’, which is being debated upon by many sexual health workers (Stammers, 2001) and includes the concept that sex should be ‘saved’ for the time when a relationship between two partners is at a high level of intimacy and commitment.
Is is suggested that at this time, the partners are able to make an informed decision that once having made love for the first time, they will continue to do so exclusively with each other for the rest of their lives. (Fu et al., 1999) With the failure of safe sex message becoming increasingly distressing, it is time for UK sex education policy-makers to take alternatives like this one seriously.
In an experiment performed by Graham et al., (2006) 278 men attending an STI clinic who had used a condom during penile-vaginal sex at least three tines in the past three months were asked to complete an anonymous questionnaire. The men were asked to report on how they used condoms, how consistently they used them, how many different sexual partners they had had in the past three years and whether they had experienced erection loss associated with condom use. The results showed that there is an association between frequent unprotected vaginal sex and condom-associated erection loss. Men who experienced erection loss were also shown to be more likely to remove condoms before sex was over.
Thus, condom-associated erection loss may be common among those at risk of STIs and the problem could result in incomplete or inconsistent condom use. Lack of confidence to use condoms correctly, problems with the fill and feel of condoms and having sex with multiple partners are identified as possible causes of condom-associated erection loss. (Graham et al., 2006) This evidence is also consistent with results of an experiment by Reece et al., 2007.
There is growing evidence that the promotion of pleasure in male and female condom use, in conjunction with safer sex messaging, can increase the consistent use of condoms and thus the practise of safer sex. (Philpott et al., 2006)
Condom use interventions and promotion
According to Philpott et al, (2006) condoms are generally perceived to reduce sexual pleasure, so it is important for public health campaigns to tackle how to increase sexual pleasure when promoting condoms. There are many reasons why people decide to practise sex without a condom. For example, there are those, who perhaps indulge in sexual activity a lot, and who are concerned about the cost of regular condom use (especially sexual ‘workers’). Further, there is a feeling of not being at risk by many people, which is often spurred by ignorance or myths concerning HIV and AIDS. There also exists the belief that condoms are not effective in preventing HIV or that requesting condom use means that you do not trust your partner. Many see condoms only as an awkward and unpleasant necessity. (Philpott et al.,2006)
Similar concerns help to explain why the use of female condoms remains very low worldwide, especially in resource-poor places. Biases by policymakers, high cost, lack of understanding of how to use them, limited supplies and access and general discomfort for both the man and the woman with touching the woman's body to insert the aid are all important factors. The most common reasons according to a study of the literature for not using condoms is that they are perceived as awkward, uncomfortable and not sexy. (Philpott, et al., 2006; Wellings et al., 2001)
It is suggested therefore that eroticising male and female condoms may be key to increasing condom use. If we make condoms more comfortable and pleasurable, this transforms them from being strictly disease-prevention and public health tools into erotic accessories, which is much more appealing. Since the advent of the HIV pandemic, in the world, the male condom has been hugely promoted as the primary means of HIV and STI prevention. However, many people still choose to have unprotected sex rather than use condoms, which shows that a change in perception is desperately required. It is clear that demand factors such as risk perception, partner reluctance, increased dryness, reduced sexual sensation, discomfort in the fit and feel of a condom and decreased spontaneity are as critical in determining condom use as factors concerning supply and demand. (Wellings et al., 2001)
According to Philpott et al., (2006), condoms can be very sexy and pleasurable and enjoyable sex can be safer. (Philpott et al., 2006)
Changing the persona of condoms has recently been the focus in the USA where in New York, there is now a ‘cool’ brand of packaged condom called The New York City Condom– the official condom of New York with a retro style case. (New York City Health, 2008) this will help to raise the profile of condoms with young people and the success of this revolutionary brand has already been documented. It is clear that the UK should now follow suit and come up with something similar to grab the attention of our young people of today to try to accessorize the condom and make it more fashionable.
This seems the obvious next step to take with condom promotion given that the many years of their promotion since the 1990s has done little to relieve the high rate of STI transmission in the UK. The only remarkable rise in condom use in Britain which is worth mentioning is the impact of the AIDS-linked safer sex messages. There are British websites available, which customize condoms at a fee to a buyer, as well as providing a range of colours, styles and flavours not already on the mainstream market (British condoms, 2008) but it is necessary to make them free and available to all if we want them to be obtained by all. It is also necessary to create a brand name if we want the condom to be successful.
According to a study by Williams et al., (2001) collected data demonstrates that frequency of sex is a key determinantfor condom use in specific sexual partnerships. The study relied on self-report of sexual relationships andbehaviour and this limitation was addressed by restricting questionsabout sexual behaviours to the last three partners and to sexin the last 30 days. By using this strategy, Williams and colleagues report that details by drug usersof their sexual behaviours are reliable and valid.
However, self reports of sexual behaviours are subject to recallbias and are difficult to verify, which remain the limiting factors of this study and the cross-sectional designof the study limits the ability to draw causal determinates. Results show that althoughthere was a clear association between frequency of sex betweenpartners and the use of condoms, causality cannot be effectively established. A furtherlimitation of a study of this nature is the number of cases which fall within partner-type categories, inparticular, in the low frequency categories. The findings of this experiment arealso quite limited because data was not extracted for condom use duringeach sexual encounter which was mentioned in the previous 30 days.(Williams et al., 2001)
Research previously done in this area of sexual health has established that there are distinct differencesin condom use by partner type. Williams et al., (2001) hypothesised thatfrequency of sex with one partner would affect condom use and the author and his colleagues produced data supporting this.
While variations in the level of condom use by partner type were identified, the data also produceda pattern of use, which was directly related to the frequency of sex between partners.Given the association between the use of condoms and thefrequency of use, it is predicted that if more data points had been available, condom use would have continued to drop as the frequency ofsex between partners increases. The association between frequencyof sex and condom use is independent of partner type, which suggestsa complex structure in the determination of condom use, and one that is also not just accounted for by partner type. (Willams et al., 2001)
In the Independent Advisory Group on Sexual Health and HIV 2006/7 annual report, it is detailed that Primary Care Trusts are rapidly separating their commissioning and provider functions and, in someinstances, actively trying to find new providers for their community services. This action has reportedly added uncertainty for certain services – for example, community contraceptive services. The Independent Advisory Group is deeply worried that there is a danger that the prevailing economic arguments behind strong sexual health and services promoting contraception will disappear unless the services are given more senior representation with PCTs.
The financial case for sexual health services has been made repeatedly and reportedly, this resulted in the Government putting 48-hour GUM access in the top six of its sexual health priorities. Further, the Government also made an allocation of £300 million of funding to support Choosing Health White Paper, which is an act that was unfortunately annulled by the financial imperative for PCTs to “balance books”. This meant that most of the funding did not reach the intended services.
Since 2006, the Department of Health commissioned the Health Economics of Sexual Health, which is a guide to commissioning and planning outlining the level of cost effectiveness on a service-by-service level.Whilst we are mentioning a failure of the government to improve services for sexual health in the UK, we will also mention the ill documentation detailing the apparent fall in STI rates by the Welsh Assembly Government in 2005, which according to data elsewhere, is not true and the publication of this claim is totally misleading to the public. (Welsh Assembly, 2005)
According to the IAG, access to GUM clinics must remain a top priority and the 48-hour access target has been an important issue to have focused attention on the care of Sexually Transmitted Infections. The improvements made over the last few years to sexual health statistics and treatment should continue to be sustained and built on. (IAG, 2007) However, it is recognized that this will prove to be a difficult task as there is still a great deal to do to make sure there is appropriate GUM access.
Recently, the Health Protection Agency (HPA) issued a warning to sexual health advisors and clinicians that an increased pressure on GUM services may jeopardize reaching the 48-hour access target, which has been identified as a top priority. The HPA also published that there was a 6 % increase in workload of GUM clinics between 2005 and 2006. (IAG, 2007)
According to the IAG (2006; 2007) the successful promotion of sexual health requires a rigorous programme of actions, which encompass the health and education sectors, as well as the broader political, economic and legal fields. In each domain, the IAG report that strong action is needed to negate the barriers to sexual health and to promote those which support it. All activities falling under the five domains (Health, education, political, economic and legal) (WHO, 2007) should be based on the recognition of the heterogeneity of gender-related power issues in controlling sexual health and also explicitly showing respect for this diversity.
Furthermore, the promotion of respect for the rights of all individuals in society should be maintained, as well as the involvement of all people, including vulnerable groups in activities to promote sexual health. An acute awareness of the need to address vulnerability to sexual health problems also needs to be maintained.
It also seems apparent that social norms should be worked on to create an appropriate environment that works for sexual health. (WHO, 2004)
In the health domain, the WHO has recognised different strategies which can be used to promote sexual health, which include providing high quality integrated sexual health services to target men and vulnerable groups with services and manage the rate of sexual violence. (WHO, 2004) In the education domain, comprehensive sexuality education for young people needs to be promoted, as well as standardization of sexuality definitions and sexual health training for health workers, teachers, social workers and youth workers.
Also, it has been suggested that some success could come from community-based implementations which aim to meet the needs of out-of-school young people and others who may be particularly vulnerable. In the main, political actions are required to activate resources for sexual health and to develop a universal agreement on the best practices and also to involve religious and community leaders in the encouragement of supporting sexual health strategies. It is apparent that certain new legislation may be required to offer support to those whose rights may be challenged and promote access to health and education services. (WHO, 2004)
A succinct account detailing the position of sexual health in the UK has been given here and we are provided with much in the way of evidence that there is widespread concern regarding the status of STI and unwanted pregnancy rates in the country at this time. Despite the increase in the rate of diseases such as Chlamydia in the UK, we are comforted by the recent recognition by the Department of Health and the World Health Organisation that sexual health is a concern which is distinct from matters concerned only with family planning and should be dealt with as a separate health issue for a more successful response to strategies aiming to reduce prevalence rates of problems.
With the realization that young people between the age of 16 and 25 are the group most at risk from sexual health problems, it is surprising that intervention has not incorporated more aggressive ways of getting the attention of this group. Furthermore, we are of the opinion that prevention is better than cure and it makes sense to begin aiming advertisements and literature at a younger audience to raise awareness even perhaps before it is physically necessary. Such methods could be adopted through the release of colourful material in teen magazines and comics for example, which is not seen presently and the invention of a synonymous New York City Condom.
What also seems necessary, since we have recently delved into such an advanced technological world, is the need for the release of multimedia adverts showing the possible causes of unprotected sex and the reinforcement of loving, caring relationships between partners in television, radio, perhaps on pop-ups on the internet and on computer games. Such advertisements could be tailored separately for boys and girls for maximum impact. To gain the most recognition of adverts, it would make sense to show, perhaps, rather graphic advertisements during the advert breaks for television shows which are popular with young people and also those which are directed at young people but have a sexual nature (such as ‘Skins’ for example).
For this to happen, it may well require that certain legislation be changed. Likewise, audio advertisements could be played particularly frequently during shows on Radio 1, which are known to be popular. Whilst it is evident that there is much work being focused on bringing down the rate of sexual ill health in young people, we suggest that the implementers do more to get into the minds of young people to find out what their views on sex and love are in the hope of better identifying areas to target.
This will mean more questionnaires in schools and universities, social clubs, youth clubs and sports clubs. More research into the psychology of children these days will also benefit strategies for sexual health and hopefully provide valuable insight into why previous intervention has remained unsuccessful in significantly reducing the effects of unprotected sex. With the historical successive failures of various intervention strategies to reduce sexual ill health in young people, we suggest that a more unconventional approach be taken and applied in alternative attempts to get the attention of young sexually active men and women.