Sexual health services are a vital part of medical and public health provision. So how are they currently configured, what services do they provide and what is the contribution of primary care? Martin Hodgson reports.
Not only does sexual health play an important part in the physical and mental wellbeing of individuals, but sexual health problems have become a major social issue in recent years. Rising rates of sexually transmitted infections, especially of chlamydia in young adults, have fuelled public concern, as have high levels of teenage pregnancies. In addition, HIV infection remains a serious priority.
What are sexual health services?
Sexual health is a wide field of medicine. In its most typical form it includes the treatment of sexually transmitted infections and diseases, sexual dysfunction and other sexuality issues. It also includes HIV services, contraception and family planning advice.
However, sexual health is much more than just about disease. It is also about attitudes and education. A key goal of services is to educate people to take better care of their sexual health and to be more aware of the possible consequences of high risk sexual behaviour, especially young vulnerable people who are most at risk.
The consequences of poor sexual health can be serious. Unintended pregnancies and high levels of abortions and sexually transmitted infections (STIs) can have a long- lasting and damaging impact on people’s lives and there is a clear relationship between sexual ill health, poverty and social exclusion. There is also an unequal impact of HIV on gay men and on certain minority ethnic groups.
Government sexual health strategy
The public health White Paper, Healthy Lives, Healthy People, commits the Government to work towards an integrated model of service delivery to allow easy access to confidential, non-judgmental sexual health services.
This aim is supported by professionals and organisations working in the field but there has been criticism that a new sexual health and HIV policy has not yet been published. The Government has responded by stating that a new sexual health and HIV policy document is being developed.
The existing strategy for England, Better Prevention, Better Services, Better Sexual Health — The National Strategy for Sexual Health and HIV, was introduced in 2001 at a time of increasing rates of sexual transmitted infections. It set up a three-level model of service provision.
Level 1 — a basic level of sexual health provision to be carried out in GP surgeries and walk-in centres which may include the provision of emergency contraception, hormonal contraception, opportunistic screening, treatment for sexually transmitted infections (STIs) and cervical cytology.
Level 2 — an enhanced level of care, which includes all of the above and some level of specialist provision. This may include intrauterine device/intrauterine system fitting, enhanced genito-urinary work which may include treating complicated STIs and contact tracing, human immunodeficiency virus (HIV) counselling, testing and treatment, and specialist training for doctors and nurses.
Level 3 — a specialist provision of sexual health care, which includes the above plus expertise in research, education and training.
The strategy aimed to reduce the spread of STIs through more rapid detection and treatment, especially for young people. It stressed that improving sexual health and wellbeing is a multi-agency responsibility and cannot be addressed through interventions delivered in specialist sexual health services alone.
With an increasing number of services being involved in sexual health care, a common set of standards for the management of STIs were developed to support the commissioning and provision of care across all settings. Standards for the Management of Sexually Transmitted Infections (STIs), produced by the Medical Foundation for AIDS & Sexual Health (MedFASH) and the British Association for Sexual Health and HIV (BASHH), bring together the key elements of best practice that people seeking help in relation to STIs are entitled to expect, whichever service they choose to attend.
In Scotland, a Sexual Health and Blood Borne Virus Framework (2011–2015) was published in August 2011. The framework builds upon Respect and Responsibility, the first national strategy for sexual health in Scotland, published by the Scottish Executive in 2005.
Respect and Responsibility has three broad aims:
to improve the quality, range, consistency, accessibility and cohesion of sexual health services from primary care to genito-urinary medicine (GUM) services
to support everyone in Scotland, including those who face discrimination
to positively influence the cultural and social factors that impact on sexual health.
The Welsh Government published its current sexual health strategy in 2010. The Sexual Health and Wellbeing Action Plan for Wales 2010 to 2015 focuses on reducing rates of STIs and tackling teenage pregnancy rates with a National Advisory Board to monitor progress.
Sexual health service providers
A range of different services and practitioners offer sexual health treatments, support and advice of varying types. These include:
sexual health clinics and GUM clinics
contraception clinics (often known as family planning clinics)
sexual assault referral centres
young people's services
local charities and voluntary groups.
Patients can search for local services through the NHS Choices website or through their local NHS websites. The NHS Direct website has an online symptom checker.
Sexual health clinics
Sexual health clinics are a key element in the provision of sexual health services and provide a direct route through to enhanced, specialist levels of care.
Different areas will have varying levels of provision through their clinics which may be referred to as Sexual Health Clinics, GUM clinics or STI clinics. Confidential advice, testing and treatment for those who are worried that they may have a sexually transmitted infection, or STI, can usually be obtained from most clinics and in many areas services can be accessed such as:
special sessions for people who have been sexually assaulted
hepatitis B vaccination
post-exposure prophylaxis (PEP)
People are able to visit any sexual health clinic they wish and do not have to go to one in their local area. Visits are free of charge and can be made on a drop-in basis without an appointment. Services are entirely confidential and people do not have to use their real name if they do not wish to.
As part of their initial consultation patients are asked about their medical and sexual history, what methods of contraception they use and questions about their sex life and sexual partners. Patients who need to be tested for STIs will usually be asked to provide a blood or urine sample.
The confidentiality of sexual health and GUM services is vital. Many people are embarrassed or unwilling to attend for sexual health advice where they think they will be recognised and may not want others to know about their consultation, not even their GP. This may be especially true of young people.
In general those under 16 years of age can expect full confidentially from a sexual health clinic and no one in their household will be contacted without their permission. However, staff may encourage them to talk to their parents, guardian or another trusted adult.
Those who have been sexually assaulted should be offered specialist service and help reporting the assault to the police, if they choose to accept it.
Services may consider passing on confidential information without permission where there is a protection or safeguarding issue or to protect someone from serious harm.
Many areas have merged their sexual health services into clinics that offer a single point of access for patients. Others retain separate clinics according to need.
Contraception or family planning clinics
Advice about contraception is primarily obtained from either a GP, a family planning clinic or a sexual health clinic. Some clinics may also provide additional services such as:
pre-pregnancy advice/pregnancy testing
help and advice on an unplanned pregnancy including abortion, adoption and continuing the pregnancy
safer sex advice
advice on sexual problems
cervical screening tests and breast awareness
checks for sexually transmitted infections
Emergency contraception is usually available through clinics and some GPs and young people’s services also offer contraception, including emergency contraception.
Many pharmacies will also be able to offer expert advice and support.
Voluntary bodies and charities
Various voluntary bodies and charities support people with sexual health needs, both at a national and local level. Examples include the FPA, Brook, the Terrence Higgins Trust and MedFASH.
These charities often campaign on sexual health issues and have joined forces in the last year to remind the Government of the importance of sexual health services and to challenge cuts which they say are beginning to undermine services.
While core clinical services generally continue despite a funding squeeze, targeted projects to groups such as young people at risk of being sexually exploited, or those with learning disabilities, are vulnerable, the charities state. They quote a growing body of evidence that choice is being restricted and services are being eroded.
Sexual health and primary care
A growing number of STIs are being diagnosed in primary care in the UK and there is an increasing engagement of GPs in managing sexual healthcare pathways, in line with the national strategy.
Encouraging people, especially young people, to access services early and receive quick and effective advice, screening, diagnosis and treatment is vital if improvements in sexual health are to be realised. Primary care therefore has a vital role to play in contraception and sexual health services. Most GPs are the first point of contact for those who are thinking about planning a pregnancy, or who have just become pregnant, and for those who require contraception advice or emergency contraception. Most GPs will also test for and treat STIs, referring on cases to specialist services where required.
Primary care can have a particularly influential role in sexual health promotion, helping patients to recognise any risk in their sexual behaviour and to behave in a safer ways.
However, despite primary care being well placed to provide advice, screening and treatment in this area, services vary and only some practices offer a range of enhanced sexual health services and have a GP or nurse who specialises in the field.
Sexually transmitted infections (STIs) are diseases that can be transmitted by unprotected sex. Combating such infections is a major element of the work of sexual health services and an important concern for general practitioners.
Genital chlamydia trachomatis is the most common STI diagnosed and treated in the UK. The Health Protection Agency report that over 186,000 new cases were diagnosed in 2011 with sexually active young adults under 25 years having the highest risk of infection.
Chlamydia often has no symptoms but can lead to a wide range of complications, including pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility in women and epididymitis in men. This represents a substantial public health problem and a National Chlamydia Screening Programme was launched in 2003 to control chlamydia through early detection and treatment, reducing onward transmission and the consequences of untreated infection.
The HPA recommends that local areas achieve a rate of at least 2400 per 100,000 resident 15–24 year olds, a level which is expected to produce falls in chlamydia prevalence.
Further details about the programme can be found at www.chlamydiascreening.nhs.uk.
Neisseria gonorrhoeae is the second most common bacterial STI in the UK. The HPA state that young people are most commonly infected, with current rates highest in males aged 20–24 years and females aged 16–19 years. The highest rates are found in London and predominantly urban areas.
Gonorrhoea is passed on through unprotected sexual intercourse and those most at risk are people with more than one sexual partner, and those who frequently change partners. The early signs of gonorrhoea are often mild and many are unaware of their infection. Symptoms in young women can include a painful and burning sensation when passing urine and discharge from the vagina that is yellow or bloody. Typical symptoms in young men include a discharge from the penis and a severe burning when passing urine.
Gonorrhoea can have especially serious effects for young women if left untreated. Young women with gonorrhoea can develop pelvic inflammatory disease and this can damage the reproductive tubes leading to the ovaries. An infected woman can pass the bacteria on to the baby during delivery causing it to be born with neonatal conjunctivitis.
As a bacterial infection, gonorrhoea can usually be treated with antibiotics, often a single dose.
Other common STIs include genital herpes and genital warts.
Symptoms of genital herpes generally start with mild soreness and groups of small painful blisters appearing on the genitals and surrounding areas. The virus can cause severe systemic disease in newborn infants and the immunosuppressed and it may facilitate HIV transmission.
Genital warts are the most common viral STI diagnosed in the UK, with highest rates of new cases in 20–24 year old men and 16–19 year old women. They are found on or around the penis, anus or vagina and the number of genital warts diagnosed in the UK population has continuously risen since records began in 1971.
Warts are caused by the human papillomavirus (HPV) which can also cause cervical cancer. Since 2008, a national HPV screening programme has sought to provide a vaccination for girls.
Sexual health services also provide the key screening source for infection with the Human Immunodeficiency Virus (HIV), which continues to be one of the most important communicable diseases in the UK. The virus infects the cells in the body that usually combat infections leaving the body susceptible to diseases it would normally be able to fight. Without treatment, the immune system will become too weak to fight off illness and a person with HIV may develop Aids, or (Acquired Immune Deficiency Syndrome).
HIV is an infection associated with high costs of treatment and significant mortality. Each year, many thousands of individuals are diagnosed with HIV for the first time, often through screening at a GUM clinic.
In recent years highly active antiretroviral therapies have resulted in substantial reductions in AIDS incidence and deaths in the UK.