Current Issues |
| May 2003 |  |
| Reasons for the nation's failing sexual health | |
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Trevor G Stammers, Tutor in General Practice St George's Hospital Medical School, London 14 May 2003 This letter appears on the BMJ's web site with reference to debate
surrounding 'Sexual health—health of the nation.' Dear Editor In 1997, Professor Adler’s stark assessment of the deterioration of sexual health of the UK [1] laid the blame for it on presumably highly influential (though unnamed) groups attempting "to withhold information on the basis of a particular agenda of family values and morality.[2] At least his 2003 editorial,[2] charting more recent decline on every parameter examined, does not repeat this former unreferenced and, in my view unsupportable, scape-goating. This time, he appears to blame the government for not making sexual health "an NHS or political priority". Whilst I agree they have not and the currently allocated financial resources are totally inadequate, it is the political correctness of sexual-health policy-makers that is the main barrier to improving the sexual health of the nation. It is widely accepted that up to 80% of unplanned pregnancies are due to contraceptive (mainly condom) failure,[3] yet condoms still continue to be promoted as a "the solution" the very problem they contribute so heavily towards.[4,5] Condoms, when used consistently and correctly, do provide reasonable protection against HIV and gonorrhoea.[6] However, they are rarely consistently and correctly used [7] and even when they are, there is no evidence that any protection they may provide against the majority of sexually transmissible agents is anywhere near as good at that for HIV;[6,8] in the case of HPV it is possibly none at all. [6,9] Adler indicates that reversing adverse trends in sexual behaviour is a key priority in controlling STI escalation. Increased condom use alone is "not enough to offset the increase in sexual partners". He also suggests the increase in sexual intercourse among under-17s as a major contributor to poor sexual health. If delaying the age of first coitus is therefore so important, why is there seemingly complete denial in the Department of Health about the effectiveness of abstinence education?[10] Both unplanned pregnancy and STI rates have been reduced in appropriate abstinence-based programmes, not only in the USA [11,12] but also in Zambia [13] and Uganda.[14] In spite of such evidence for their effectiveness, abstinence programmes are labelled in the UK as being unworkable.[15] Instead we continue to base our programmes for reducing unplanned pregnancy on condoms, the failure of which is implicated in 80% of them. More recently the emphasis has switched to the emergency pill, but the unrestricted use of this from pharmacies will only further the increase in STIs.[16] Until such short-sighted policies change, we will indeed sadly "witness failure upon further failure" in sexual health in the UK. However, Professor Adler has not told us the real reasons why. References (1) Adler M. Sexual health- a Health of the Nation failure. BMJ 1997;314:1743-1747. (2) Adler M Sexual health – health of the nation. Sex Trans Infec 2003;79:85-7. (3) Pearson VAH, Owen MR, Phillips DR, Pereira Gray DJ, Marshall MN. Pregnant teenagers’ knowledge and use of emergency contraception. BMJ 1995; 310:1644 (4) Richens J, Imrie J, Copas A Condoms and seat belts: the parallels and the lessons Lancet 2000 355 400-3 (5) Doughty S Charity to hand out free condoms to 11-yr olds Daily Mail 28.3.2003 http://www.likeitis.org.uk/welcome_to_like_it_is.html (6) http://www.niaid.nih.gov/dmid/stds/condomreport.pdf (7) de Visser RO Smith AM When always isn’t enough; implications of the late application of condoms for the validity and reliability of self- reported condom use. AIDS Care 200012:221-4. (8) Mann J, Stine C, Vessey J The role of disease-specific infectivity and number of disease exposures on long-term effectiveness of the latex condom. Sex Trans Dis 2002;29:344-9. (9) Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection, external genital warts or cervical neoplasia? A meta-analysis. Sex Trans Dis 2002;29:725-35. (10) CMO’s Update 35 DoH Jan 2003: http://www.doh.gov.uk/cmo/cmo_35.htm#10 (11) Doniger AS, Adams E, Riley JS, Utter CA, Impact evaluation of the "Not Me, Not Now”' abstinence-oriented, adolescent pregnancy prevention communications program, Monroe County, New York. J Health Communication 2001;6:45-60. http:// www.notmenotnow.org/research/NMNNimpactevaluation.pdf (12) Mohn JK, Tingle LR, Finger R An analysis of the causes of the decline in non-marital birth and pregnancy rates for teens from 1991 to 1995. Adolesc and Fam Health 2003;3:39-47. (13) Martin K Zambia’s HEART programme evaluation shows youth respond positively to AIDS prevention plan promoting abstinence. John Hopkins University Centre for Communications Programmes 2002. http://www.jhuccp.org/pressroom/2002/07-11.shtml (14) Hogle J, Green EC, Nantulya R, Stoneburner J et al. Whatever Happened in Uganda? Declining HIV prevalence, behaviours change and the national response USAID-Washington and The Synergy Project TvT Associates Washington D.C. 2002 http://www.usaid.gov/pop_health/aids/Countries/africa/uganda_report.pd (15) Swann C, Bowe K, McCormick G, Kosmin M Teenage pregnancy and parenthood; a review of reviews. Health Development Agency 2003. (16) Stammers T. Emergency contraception from pharmacists misses opportunity. BMJ 2001;322:1245. |