Saturday, 25 February 2017

Vice Nation - Sex V: Sexual Health

(Pic : trendycrunch.com)
Like anything involving contact with bodily fluids, there's always some measure of risk attached. This is going to be a pleasure to bring to you.


What is "safe sex" in the first place?

Ultimately, it means reducing the risk of catching or exposing yourself to sexually-transmitted diseases (STDs) or an unplanned pregnancy. Most of it's common sense and basic decency, but could include:

  • Respecting consent (Part I) and not coercing or guilt-tripping partners into doing something they don't want to do.
  • Using, or insisting on using, condoms or other forms of contraception (whether you're planning on having a child or not) - particularly for one night stands.
  • Only having unprotected sex with a regular partner in a committed relationship. You need to know where they've been, to put it bluntly.
  • Undergoing health screening if you engage in behaviours that put you at a statistically higher risk of catching an STD (i.e. porn actors, anal sex).
  • If you do catch an STD, informing all past and present sexual partners as soon as possible.

Some of the more common STDs include:

Parasitic infections – The most common are public lice (aka. crabs), trichomoniasis and scabies. There are also certain parasites that transfer almost exclusively through anilingus (aka. rimming) like cryptosporidium, giardiasis and amebiasis. They're usually only prevalent in countries with poor sanitation because they exist in faecal matter....so much for the "booty eating renaissance".

Herpes – Viral infection caused by variants of herpes simplex virus transmitted by contact with skin or bodily fluids carrying the virus. The outward symptoms are blisters and sores. There's no cure as such, but the symptoms can be treated with anti-virals and topical creams.

Chlamydia – The most common STD. A bacterial infection that causes discharges from the genitals and pain during urination. It can be treated with antibiotics, but if left untreated complications can cause infertility in women and blindness (traucoma). It can also be passed from mother to child during childbirth.

Gonorrhoea – Aka. "The Clap". Another bacterial infection that has symptoms similar to chlamydia and can also be passed from mother to child during childbirth. Although it can be treated with antibiotics, the disease is rapidly becoming resistant and may soon be untreatable.

Syphilis – Bacterial infection that causes ulcers, rashes and sores all around the body, as well as other symptoms like fever and joint pain that can last for several weeks. It can be treated with antibiotics, but if left untreated it can re-emerge decades after the original infection to cause serious deformities and attack the nervous system (neurosyphilis).

Hepatitis B & C – Viral infection that causes inflammation of the liver resulting in number of symptoms such as jaundice, tiredness and abdominal pain. It's transmitted through contact with infected blood or bodily fluids. It's usually not fatal but can develop into cirrhosis. There's a vaccination available against Hep. B, but none for Hep. C.

Human Papillomavirus (HPV) – A virus known to cause warts and lesions that can lead to oral, throat, anal, penile, vulval and cervical cancers. In Wales there's currently a vaccination programme for girls aged 12 and 13 and has also started being offered to sexually-active gay men from December 2015.

Acquired Immunodeficiency Syndrome (AIDS)
– The disease caused by the Human Immunodeficiency Virus (HIV). As the name suggests it reduces the effectiveness of the immune system, leaving sufferers more vulnerable to common infections and certain forms of cancer. Retro-viral treatments have improved to the extent that people with AIDS can live relatively normal lives (similar to diabetics), but there's no cure and as HIV is present in the blood as well as sexual fluids it can be transmitted through shared needles, blood transfusions or from mother to child during pregnancy – not just sex.

Sexual Health in Wales

The following is based on Public Health Wales' quarterly sexual disease monitoring report from October 2016 (pdf).


So overall, there's probably more good news than bad with rate of STDs generally falling across the board.  However, the more worrying aspect is that the most common STD – chlamydia – is continuing to see year-on-year increases and, as mentioned earlier, it can cause serious problems if left untreated.

So another bit of good news is that more people are being screened overall, and there've been improvements in the Hywel Dda health board region (Carmarthenshire, Pembrokeshire, Ceredigion) in particular.

STD rates remain disproportionately higher amongst gay and bisexual men as a group. There's a discriminatory stereotype that MSM are more promiscuous than the general population, but it's more likely to be simple anatomical reality. Anal sex is more risky regardless of who's doing because the lining of the rectum is easier to damage, meaning more exposure to blood and semen (in addition to faeces). A common myth is the "top" (the one doing the penetrating) is generally at lesser risk of catching an STD than the "bottom" but that's simply not true.

Maybe there's still a level of ignorance in the population about risks from oral sex too – it's far from "safe". This suggests safe sex campaigns have been too focused on avoiding pregnancy and not enough has been done to target relevant information at LGBTs (and, indeed, straight couples) on forms of sex other than vaginal.

Generally though, although HIV/AIDS is probably the STD everyone's most worried about, the number of cases each year are relatively small. The same goes for syphilis and hepatitis. This is a sign that the aggressively bleak public information campaign in the 1980s (Don't Die of Ignorance) did the trick – and counts as one of Margaret Thatcher's positive legacies.

Treating & Monitoring Sexual Diseases

(Pic : via Twitter)

The job of monitoring sexual infections is the responsibility of Public Health Wales, who publish quarterly reports on rates of STDs (as utilised earlier).

The first port of call for anyone who suspects they have an STD will probably be their GP or pharmacist as soon as symptoms develop.

After that, patients will probably be referred to one of NHS Wales' integrated genito-urinary medicine (GUM) clinics, which provide STD testing, contraception and family planning advice, vaccinations as well as preventative services and emergency assistance such as emergency contraception or dealing with sexual assaults (Part II).

In many cases GUM clinics are nurse-led, but often have limited appointment-only opening hours with staff shared between multiple sites.

There's an All-Wales Sexual Health Network and an All-Wales AIDS Network, both of which are now under Public Health Network Cymru. The goal is to share information and best practice between people working in sexual health – whether in the NHS or other organisations.

At time of writing this the Welsh Government's five-year sexual health strategy was still under review, the previous one running between 2010-2015. As you might expect the overarching goal of the strategy is to – shock, horror – improve sexual health.

Third Sector bodies also play a vital role, in particular when it comes to AIDS patients and people who've contracted HIV. The stigma perhaps isn't quite as bad as it was when HIV and AIDS first appeared, but it's still there, and organisations like the Terrence Higgins Trust and Body Positive Cheshire & North Wales promote HIV testing and advocate on behalf of patients.

Most treatments will be standard medicines like antibiotics and creams, whether delivered through pharmacies or in hospital.

AIDS is perhaps the big exception. As mentioned earlier, retro-virals can be used effectively when treating AIDS, but there are also newly-emerging treatments which can reduce the chances of at-risk groups catching HIV (i.e. sexually-active gay and bisexual men, drug addicts).

These pre-exposure prophylaxis (PrEP) drugs can reduce the risk of contracting HIV by between 70-90% - but they're pricey, often costing between £40-80 a month (£480-960 a year), and despite being trialled are currently not available on the NHS in Wales – though they were approved for the NHS in England in December 2016. The Liberal Democrats have argued they should be available.

Although not strictly STDs, there's a routine screening programme for cervical cancer via Cervical Screening Wales. All women between the ages of 25 and 65 are invited for smear tests either every three or five years depending on age. There are tests for ovarian cancer as well, but it's not done routinely. This means that although the disease is often relatively easy to treat when caught early, many women don't get tested until the symptoms are obvious and by then it may be too late.

There have been concerns that women under the age of 25 find it hard to get smear tests following a raising of the age at which women are invited from 20 to 25 in 2013 (because cervical cancer is incredibly rare in the under-25s). Meanwhile, the Assembly's Petitions Committee recently flagged up limited access to blood tests for ovarian cancer because of concerns over the test's reliability (I'll come back to that another time).

Teen Sex & Teen Pregnancy

The age of consent might be 16, but that's not going to stop anyone under that age "experimenting". According to (somwhat outdated) statistics from the FPA charity (pdf), the median (middle average) age by which heterosexual men and women lose their virginity was 16, meaning a large number of people - up to a third - have sex before the age of consent. There were no statistics for lesbians, but for gay and bisexual men, the average age was older at 17.5 for any sexual contact rising to as old as 20 for anal sex.

The latest annual statistics, which date from 2014 (xls - Table 5), show the conception rate for under-16s in Wales has fallen from 7.1 per 1,000 people in 2009 to 4.9 per 1,000 people in 2014. Although conception rates remain higher than the English average (4.4 per 1,000), Wales performs better than most English regions.

Underage conceptions remain rare with only 248 recorded in Wales in 2014
(though three local authority figures remained confidential). 55.2% of Welsh underage conceptions were aborted – a much lower proportion than the EnglandandWales average of 62.5%.

(Click to enlarge)

Top of the pile is Bridgend, at 7.5 underage conceptions per 1,000 people, closely followed by Caerphilly (7.2) and Torfaen (7.1). Teen mothers in Bridgend also kept more of their babies than anyone else with only 22.2% of conceptions resulting in abortion, compared to 55.9% in Neath Port Talbot, 78.9% in Rhondda Cynon Taf and 100% in Monmouthshire.

When it comes to conceptions amongst under-18s (so including 16, 17 and 18 year old mothers) the picture changes.

(Click to enlarge)

Bridgend still remains top (32.1 conceptions per 1,000 residents), but the other south Wales valley authorities - Rhondda Cynon Taf (31.4), Torfaen (28.8), Merthyr Tydfil (27.9), Neath Port Talbot (27.3) – catch up. Denbighshire (30.8) and Conwy (30) are outliers, but there's clearly a correlation between relative deprivation and high levels of young conceptions.

The abortion rate also lowers once older mothers are added to the under-16 figures – from 55.2% to 45.3%. The only local authorities where the abortion rate remains above 50% are Monmouthshire (72%), Conwy (64.4%), Gwynedd (55.3%), Ceredigion (54.2%) and Rhondda Cynon Taf (50.4%).

Just like under-16s, the trend for 18-and-under year old conceptions and births has been downwards, having almost halved from 55.5 conceptions per 1,000 residents in 1998 to 25.4 per 1,000 in 2014.

This has been attributed to wider access to information relating to sex online and the rise of social media, where young people are perhaps more likely to "interact" with each other over Facebook, Instagram and Snapchat than meet in person. That might sound positive, but could also be linked to a rise in "sexting" and other forms of online abuse like revenge porn.

Biologically-speaking, the optimum age for women to have children is in the late teens to early 20s, so in the strictest sense 16-18 year olds having children isn't that odd. It's the social, educational and economic pressures that result from having children that push the optimum age further into the 20s.


Being a parent at such a young age will obviously limit opportunities, and that explains the high abortion rate for under-16s. Pregnancy and childbirth makes staying in full-time education more difficult and, as a result, might lead to limited career opportunities or, it has to be said, a life of welfare dependency.

Sexual Health, Devolution & Independence

Nearly all matters relating to sexual and public health are devolved (abortion is the big exception), so independence isn't required here. However, independence might lead to a break from the prevailing wisdom in the UK and encourage public health officials and governments to learn from examples around the world.

As for what could be done differently:


Preventative Medicine


  • The HPV vaccine could be offered to teenage boys aged 12 in addition to girls. A two-dose course (£340) for boys would cost an additional £5.7million a year (based on mid-2015 estimates of 16,700 12-year-old boys in Wales).
  • Women under the age of 25 who have a family history of cervical cancer should be eligible for smear tests on the same basis as women over-25, or at the very least be given the option of getting a smear test done. The situation for ovarian cancer is more difficult but, again, if there's a history of the disease in the family it's perhaps best to err on the side of caution and get tests done.
  • Due to increased antibiotic resistance creating super-strains of gonorrhoea and chlamydia, it may be worth investigating whether a national Centre for Sexual Disease Control could be established in Wales, focusing on research and public information.
  • Condoms could be available for free from all (not some) GP surgeries, GUM clinics, primary care centres and university health centres, possibly schools in areas with high rates of teenage pregnancy too (by appointment with a school nurse or counsellor and only to the over-14s).

Sexual Health Services & Information (Part VI)

  • GUM clinics – particularly those in urban areas – could trial a 24-hour on-call service, mainly to collect evidence in sexual assault and rape cases (perhaps working in tandem with Third Sector organisations).
  • The policy of confidentiality for patients seeking contraception (or contraception advice) when they're under 16 should continue, but staff should be trained to look for signs of abuse.
  • As mentioned earlier, how sexual health information is presented to, and understood by, LGBTs should be reviewed. Subjects like oral and anal sex need to be broached in sex education (Part VI).

General Well-being

  • VAT shouldn't be (re)applied to tampons and sanitary pads/towels/liners (aka. the "Tampon Tax", which was abolished in 2016 in the UK after negotiations with the EU Commission). VAT - currently applied at 5% - should also be scrapped for condoms and other forms of contraception, some of which don't have VAT applied anyway.
  • There needs to be a national review of the support offered young mothers, particularly in accessing further and higher education and improving job prospects. Flying Start style centres could be set up at college campuses and universities in areas with high levels of teenage pregnancy, and universal free child care for full-time students should be considered (in Wales support is currently based on income AFAIK).
  • Nowhere near enough is being done to underline to young fathers what their responsibilities or obligations are due to sexist (and on occasion racist) stereotyping. Too much is being left to young mothers while the welfare and social service system might lock young fathers out of the lives of their children, deliberately or indirectly. Boys need to be taught about pregnancy and children too and shouldn't be left off the hook.
  • Consideration should be given to including (more) sex-related questions in the National Health Survey, including porn use, sexual problems, type of sex, abuse etc. (more in Part VI). Relationship satisfaction could also be part of criteria used to measure "National Happiness". The Welsh birth rate is too low and encouraging stable relationships and more childbirths will serve us well in the longer-run.
  • Speaking of National Happiness/Wellbeing - sex, relationship and marriage counselling/therapy could be part-subsidised by the NHS (some GP surgeries already offer it) if it's contributing to diagnosed mental health or fertility problems.

Finally, Part VI addresses the most important tool in the fight to prevent STDs, domestic violence, sexual crimes and teen pregnancy: sex and relationship education.

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