Sex, health, and society: ensuring an integrated response

Abstract

Earlier this month, the President of the UK Faculty of Public Health, John Ashton, made the unsurprising claim that adolescents have sex. He went on to propose that the age of consent for sex be reduced to 15 years, and he called for a public debate about the issue. Within 24 hours the Government and Opposition leaders had all condemned him. But it was hard to know if they were condemning him because of what he had to say about the age of consent or because of their unwillingness to engage in a public discussion about adolescent sexual behaviour. Once again, Britain seemed unable to have a mature debate, informed by evidence, about sexual health. The publication of six papers from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) in today's Lancet aims to provide that firm platform of evidence for a better public, indeed political, debate about sexual health in Britain today. The first two surveys, Natsal-1 and Natsal-2, took place in 1990–91 and 1999–2001, respectively, and the studies have been a vital resource for scientists, clinicians, and policy makers. Natsal data have informed the creation of transmission models of HIV and sexually transmitted infections (STIs); guidance on legislative reform regarding the age of homosexual consent; planning of contraceptive and HIV and STI services; and development of national public health strategies, such as the national chlamydia screening programme, the teenage pregnancy strategy, and the HPV vaccination programme. These data have been used in print, broadcast media, and on sexual health service websites, providing a reliable and authoritative source of data for the public. Natsal-3 surveyed 15 162 men and women in 2010–12. It provides updates on prevalence estimates of well-known adverse outcomes of sexual behaviour in the population, such as STIs and unplanned pregnancy, but includes, for the first time, data from people up to 74 years of age, responses to more general health questions, and a focus on the quality of sexual experiences. Also, the first British prevalence figures of non-volitional sex are reported. These additions have allowed the authors to examine changes in sexual lifestyle over time, and to better study the relationship between general physical and sexual health. These issues are important because Natsal-3 data provide the most reliable evidence (and case) for establishing integrated sexual health services. Yet, from April, 2013, the provision of these services was divided between three organisations. Local authorities will be responsible for STI testing and treatment, teenage pregnancy and specialist services, HIV prevention, and the promotion of sexual health. Clinical commissioning groups will provide abortion, sterilisation, vasectomy, and gynaecological services. And NHS England will be responsible for contraceptive services through general practitioners, HIV treatment and care, cervical screening, sexual health in prisons, and sexual assault referral centres. As a result, sexual health services have been fragmented and made unprecedentedly complex, with huge variations in their provision across the country. There is concern that the diverse sexual health needs identified in this series of Natsal papers may not be fully addressed by the service reforms introduced by the Coalition Government this year. There is another anxiety. Sexual health has a social context. Poor sexual health is not evenly distributed across society. It is linked closely to deprivation and is associated with particular disadvantaged groups within the population. Some of these populations face stigma and discrimination, reducing their access to sexual health services. Any response to the challenges set out in these Natsal papers will require attention to the social determinants of sexual health, as well as to clinical need. There is also a global dimension to this work. Natsal's findings provide a better understanding for the role of sex in people's lives. The authors argue for a holistic approach to sexual health and the need to move away from disease-focused biomedical framework to a broader concept of wellbeing. Indeed, as the discussions for the post-2015 development agenda also shift away from disease and towards wellbeing, there is an opportunity to bring out the positive contribution of sex in the global wellbeing agenda. Sex is a dimension of every person's life everywhere. In conclusion, we call on the UK Government to initiate an urgent review of sexual health services. It is essential that integrated sexual health services are fully achieved to meet the public need set out clearly by the Natsal investigators. The depth and breadth of our understanding of sexual health, shown by their work, indicates that the present arrangements for delivering sexual health services may be severely deficient. Framing sexual health research: adopting a broader perspectiveThe results of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3), in The Lancet, provide extensive data from a large, representative population sample collected with the aim of better understanding sexual lifestyles and improving sexual health.1–6 Major advances in research on sexuality and sexual lifestyles have been made in the past 25 years. When the first large-scale surveys of sexual behaviour were undertaken in the 1980s—the impetus provided by the emergence of the HIV epidemic—they were politically controversial in the UK and elsewhere. Full-Text PDF Open AccessStudying sexual health in the UKThe National Survey of Sexual Attitudes and Lifestyles has been crucial in shaping sexual health services to meet the needs of the UK population, say experts. Nayanah Siva reports. Full-Text PDF Kaye Wellings: pioneering figure in sexual healthKaye Wellings is Professor of Sexual and Reproductive Health Research at the London School of Hygiene and Tropical Medicine (LSHTM), and co-leader of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3) published in The Lancet. She prefers to think in terms of sexual evolution rather than revolution when looking back to the time when she left school in York to study social science at London University during the late 1960s. “Moving to London at that time was like moving forward a decade”, she recalls. Full-Text PDF Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)Sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour seeming greater in women than men. The continuation of sexual activity into later life—albeit reduced in range and frequency—emphasises that attention to sexual health and wellbeing is needed throughout the life course. Full-Text PDF Open AccessPrevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)STIs were distributed heterogeneously, requiring general and infection-specific interventions. Increases in testing and attendance at sexual health clinics, especially in people at highest risk, are encouraging. However, STIs persist both in individuals accessing and those not accessing services. Our findings provide empirical evidence to inform future sexual health interventions and services. Full-Text PDF Open AccessThe prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)The increasing intervals between first sexual intercourse, cohabitation, and childbearing means that, on average, women in Britain spend about 30 years of their life needing to avert an unplanned pregnancy. Our data offer scope for primary prevention aimed at reducing the rate of unplanned conceptions, and secondary prevention aimed at modification of health behaviours and health disorders in unplanned pregnancy that might be harmful for mother and child. Full-Text PDF Open AccessSexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)Wide variability exists in the distribution of sexual function scores. Low sexual function is associated with negative sexual health outcomes, supporting calls for a greater emphasis on sexual function in sexual health policy and interventions. Full-Text PDF Open AccessAssociations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)Poor health is independently associated with decreased sexual activity and satisfaction at all ages in Britain. Many people in poor health report an effect on their sex life, but few seek clinical help. Sexual lifestyle advice should be a component of holistic health care for patients with chronic ill health. Full-Text PDF Open AccessLifetime prevalence, associated factors, and circumstances of non-volitional sex in women and men in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)These data provide the first population prevalence estimates of non-volitional sex in Britain. We showed it to be mainly an experience of young age and strongly associated with a range of adverse health outcomes in both women and men. Full-Text PDF Open Access