Sexual health is an important area of public health. Most of the adult population of England are sexually active and access to quality sexual health services improves the health and wellbeing of both individuals and populations. The Government has set out its ambitions for improving sexual health in its publication, A Framework for Sexual Health Improvement in England (Department of Health, 2013).
Sexual ill health is not equally distributed within the population. Strong links exist between deprivation and sexually transmitted infections (STIs), teenage conceptions and abortions, with the highest burden borne by women, men who have sex with men (MSM), teenagers, young adults and black and minority ethnic groups. Similarly Human Immunodeficiency Virus (HIV) infection disproportionately affects MSM and Black Africans in the UK. Some groups at higher risk of poor sexual health face stigma and discrimination, which can influence their ability to access services.
Sexual health can affect a person’s physical and mental wellbeing. Poor sexual health has significant negative consequences, namely:
- Teenage parenthood reduces the life chances of children and young people, and their children
- Sexual exploitation may lead to lifelong mental wellbeing problems
- STIs can cause long term and life threatening complications, including infertility
- Bullying and discrimination can occur on the basis of sexuality and gender identity
- Late diagnosis of HIV leads to avoidable serious illness and premature death as well as increased infection rates
Public Health England (PHE) publish annual Sexual and Reproductive Health Profiles for each area of England. The latest for Somerset was published in December 2017 and is available at Sexual and Reproductive Health Profile - Somerset 2017. The profile provides a snapshot of sexual and reproductive health across a range of topics including teenage pregnancy, abortions, contraception, HIV and sexually transmitted infections. Wider influences on sexual health such as alcohol use, and other topics relating to teenage pregnancy such as education and deprivation level, are also included.
Indicators are updated throughout the year and are available on the PHE interactive profile tool.
Key Messages for Somerset
- Significant progress has been made in reducing teenage conceptions, with a 55.2% reduction in Somerset between 1998 and 2016. However there are some wards where teenage conceptions are significantly higher than the England average and teenage pregnancy particularly affects young people from the most deprived areas
- STIs disproportionately affect young people and in 2016 South West residents aged between 15 and 24 years accounted for 57% of all new STI diagnoses. Chlamydia is the most common sexually transmitted infection (STI) diagnosed in young people in Somerset and whilst the number of positive tests has risen Somerset remains below the recommended diagnostic rate.
- The number of new STIs diagnosed in the South West fell by 2% between 2015 and 2016 particularly in some of the 5 major STIs – gonorrhoea, genital herpes and genital warts. However there were increases in syphilis and chlamydia and STIs disproportionately affect MSM, young people and black Caribbeans.
- HIV prevalence remains low in Somerset and the South West accounts for 5% of new diagnoses in the UK. The late diagnosis of HIV is high in some parts of the South West including Somerset with important implications for health and wellbeing and ongoing transmission.
- Health promotion and education are essential for the prevention of teenage pregnancy and sexually transmitted infections and good quality Personal, Social, Health and Economic (PSHE) education is important for the development of healthy relationships and helping children and young people stay safe. The mandation of Relationship and Sex Education (RSE) from Autumn 2019 is a good opportunity to improve the offer in educational establishments across Somerset.
- Access to free and confidential contraceptive and sexual health services are essential for preventing unplanned pregnancy and for the diagnosis and treatment of STIs and the prevention of onward transmission. In April 2016 specialist sexual health and contraceptive services were integrated to form the Somerset Wide Integrated Sexual Health Service (SWISH). This provides a ‘one stop shop’ offering free and open access to contraceptive and sexual health services to support healthy sexual and reproductive choices as well as providing targeted sexual health promotion, HIV prevention and support to people living with HIV through The Eddystone Trust . More information can be found at swishservices.co.uk
Teenage conceptions and pregnancy
Teenage pregnancy is strongly associated with the most deprived and socially excluded young people. Difficulties in young people’s lives such as poor family relationships, low self-esteem and unhappiness at school also put them at greater risk. Rates of teenage pregnancy are far higher among deprived communities, so the negative consequences of teenage pregnancy are disproportionately concentrated among those that are already disadvantaged.
The poorer outcomes associated with teenage motherhood also mean the effects of deprivation and social exclusion are passed from one generation to the next. Evidence shows that having children at a young age can damage young women’s health and wellbeing and severely limit their education and career prospects. Whilst young people can be competent parents, longitudinal studies show that children born to teenagers are more likely to experience a range of negative outcomes in later life and are up to three times more likely to become a teenage parent themselves.
At age 30, women who are teenage mothers are 22% more likely to be living in poverty than mothers giving birth aged 24 or over, much less likely to be employed or living with a partner and 20% are more likely to have no qualifications.
Teenage mothers have three times the rate of post-natal depression of older mothers and a higher risk of poor mental health for three years after the birth. The infant mortality rate for babies born to teenage mothers is 60% higher than for babies born to older mothers. Teenage mothers are more likely to smoke during pregnancy and less likely to breastfeed, both of which can affect the health outcomes of their babies.
On 21st May 2013, the Department for Education published a research report: Teenage Pregnancy in England (Centre for Analysis of Youth Transitions, CAYT). The study aimed to identify risk factors associated with teenage pregnancy, and provides some useful insights to inform the targeting of prevention strategies at individual, school and area levels:
- Eligibility for free school meals and being persistently absent from school are the most strongly individual characteristics associated with teenage conceptions and the decision to continue with a pregnancy.
- Low prior educational attainment is also associated with a higher risk of conceiving as a teenager and of deciding to continue with a pregnancy. Deterioration in academic performance between Key Stages 2 and 3 (ages 11 and 14) is a strong risk factor.
- Multiple maternities are more common amongst girls who are eligible for free school meals.
- Girls who attend higher performing schools are less likely to conceive and more likely to have an abortion if they do conceive.
- Girls who conceive achieve fewer GCSE passes and are less likely to continue in post-compulsory education (at a sixth form attached to a school) than those who do not. This relationship is stronger for girls who continue with their pregnancy, but those who conceive and have an abortion also have significantly fewer GCSE passes and are substantially less likely to stay in education than girls who do not conceive.
- Teenage conception and maternity rates are higher in deprived areas even after accounting for the characteristics of the girls themselves and the schools they attend.
- Girls living in deprived areas are also disproportionately more likely to have more than one conception before the age of 18 that results in a maternity.
In particular, the data published by the Office for National Statistics (ONS) show that:-
- There were 497 conceptions amongst 15-17 year-old females recorded in Somerset in the three year-period 2014-16;
- The conception rate was 17.3 per 1000 females in the age group, below the England rate (20.8) but slightly higher than the South West rate of 17.1.;
- Teenage conceptions in Somerset for the period 2014-2016 decreased by 54%, similar to England (54%) and the South West (55%).
- The decrease in teenage conceptions in each of the districts for the three year period 2014-2016 compared to 1998-00 was fairly similar ranging from 51% to 55%. However some wards have teenage pregnancy rates significantly higher than the England average. The latest teenage conception ward data (2013-2015) identified hotspot wards within Sedgemoor and South Somerset.
- 55.4% of teenage conceptions in Somerset for the period 2014-2016 led to abortion, slightly higher than national and regional percentages.
- There were 9,189 under 16 conceptions in England in the three year period 2014 to 2016, equating to a rate of 3.7 conceptions per 1,000 girls aged 13-15 (South West 3.0)
- The number of conceptions in this age group has fallen in England by 56% since 1998-00 (South West 60%)
- The proportion of under 16 conceptions in England leading to abortion was 62% (South West 65%)
- In Somerset, there were 78 conceptions to girls aged 13-15 between 2014 and 2016 (a rate of 2.9 per 1,000), a decrease from the rate of 6.1 in 2008-10 and a 62% reduction from 1998-00. 68% of these conceptions led to abortion.
The earlier abortions are performed the lower the risk of complications. Prompt access to abortion, enabling provision under 10 weeks gestation, is also cost-effective and an indicator of service quality. In particular, an increased proportion of abortions carried out within 10 weeks gestation demonstrates improved access to abortion services.
Furthermore, all women should have a choice of suitable procedure, whether medical or surgical, and this is most likely achieved if the abortion pathway has minimal delays.
- The number and rate of abortions in Somerset remains similar year on year, with 1238 abortions in 2016, a rate of 14.3 per 1000 women aged 15-44. The rate is similar to the South of England and lower than the England rate of 16.1
- Repeat abortion rates amongst women aged under 25 were 21.8% in 2016, lower than England and the South West.
- The highest rate of abortions in Somerset is for women aged 20-24 with a rate of 24.3 per 1000 women in this age group.
- In 2016 54% of abortions for Somerset women were medical and 46% were surgical which was similar to the South West but a lower proportion of medical compared to England (61.2%).
- 55.4% of teenage conceptions in Somerset for the period 2014-2016 led to abortion, slightly higher than national and regional percentages.
With the introduction of a Central Booking Service, self-referral and the commissioning of a range of abortion services accessible from all parts of the county Somerset has experienced a significant improvement in the proportion of women accessing abortion within 10 weeks gestation. It has more than doubled from 40% in 2006 to 82.7% % in 2016.
Sexually Transmitted Infections
Chlamydia is the most common bacterial sexually transmitted infection in England, with rates substantially higher in young adults than any other age group.
- The chlamydia detection rate for Somerset increased in 2016 at 1815 per 100,000 15-24 year olds remaining lower than the national rate of 1882 but higher than the South West rate of 1774. This increase demonstrates that the programme is becoming more successful in identifying and treating chlamydia in young people most at risk in Somerset, although the proportion of Somerset young people screened is 18.7% compared to 20.7% nationally and 21.6% regionally.
Gonorrhoea is used as a marker for rates of unsafe sexual activity. This is because the majority of cases are diagnosed in GUM settings, and consequently the number of cases may be a measure of access to STI treatment. Infections with gonorrhoea are also more likely than chlamydia to result in symptoms.
- The diagnosis rate per 100,000 population in Somerset in 2016 was 12.8, well below the national and regional rates of 64.9 and 25.7, respectively but an increase on the previous year.
Syphilis is an important public health issue particularly (but not exclusively) affecting men who have sex with men (MSM) among whom incidence has increased over the past decade. Syphilis is primarily diagnosed in GUM/Sexual Health clinics.
- In 2016, the rate of diagnoses in Somerset was 1.8 per 100,000 population below the national and regional rates of 10.6 and 3.0, respectively but an increase on previous years.
Genital Warts and Herpes
Genital warts are the second most commonly diagnosed STI in the UK and are caused by infection with specific subtypes of human papillomavirus (HPV). Recurrent infections are common with patients returning for treatment. Rates of diagnosis have decreased nationally and in Somerset.
- The first episode diagnosis rate per 100,000 population in Somerset in 2016 was 81.6, below the national and regional rates of 112.5 and 115.9, respectively
See also Cancer
Genital herpes is the most common ulcerative sexually transmitted infection seen in England. Infections are frequently due to herpes simplex virus (HSV) type 2, although HSV-1 infection is also seen. Recurrent infections are common with patients returning for treatment.
- The first episode diagnosis rate per 100,000 population in Somerset in 2016 was 25.7, below the national and regional rates of 57.2 and 49.0, respectively.
Knowledge of local diagnosed HIV prevalence and identification of local risk groups can be used to help direct resources for HIV prevention and treatment.
- The prevalence of diagnosed HIV infection per 1,000 persons aged 15 to 59 years in Somerset in 2016) was 0.77, well below the national and regional rates at 2.31 and 1.20 respectively, and one of the lowest rates of any upper-tier authority in the South West.
- The new HIV diagnostic rate per 100,000 people aged 15+ in Somerset was 3.9, much lower than the England rate of 10.3
- The number of diagnosed individuals living in Somerset has risen from 171 in 2013 to 212 in 2015.
HIV testing is integral to the treatment and management of HIV. Knowledge of HIV status increases survival rates, improves quality of life and reduces the risk of HIV transmission.
- In 2016 HIV testing coverage in sexual health services in Somerset was only 51.4% significantly lower than the South West (71.8%) and England (67.7%).
- The proportions of eligible new GUM clinic attendees (defined as a patient attending a GUM clinic at least once during a calendar year, excluding those known to be HIV positive, or for whom a HIV test was not appropriate) in whom a HIV test was accepted were 81.3% for men who have sex with men, 72.4% for all men and 40.1% for women.
- These figures are much lower than previously achieved in Somerset (and lower than the national figures) and need to be treated with some caution, particularly the percentage of women, due to the change in specialist sexual health services during 2016.
Late diagnoses of HIV is one of the Public Health Indicators and is the most important predictor of morbidity and mortality of those living with the HIV infection. It is essential in evaluating the success of access to HIV testing. Late diagnoses data are for those aged 15 years and over and is presented as 3 year combined data due to the small numbers in individual years.
- In Somerset the percentage of late diagnoses of those newly diagnosed with HIV in the period 2014-16 was 48.8%, higher than the South West at 42.9% and England at 40.1%.
- Whilst late diagnosis remains high in Somerset this shows a substantive decrease compared to the 61.3% reported for 2011-13.
HIV Support and treatment services in Somerset
As part of the new Somerset-wide Integrated Sexual Health service (SWISH), The Eddystone Trust provide support services in Somerset for people living with HIV. HIV treatment services commissioned by NHS England are provided through Taunton and Somerset NHS Foundation Trust and for both Musgrove Park and Yeovil District Hospitals.
Female Genital Mutilation (FGM)
Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.
Procedures are mostly carried out on young girls sometime between infancy and age 15, and occasionally on adult women. The practice is most common in much of northern Africa, some countries in Asia and the Middle East, and among migrants from these areas. In Africa alone, more than three million girls have been estimated to be at risk for FGM annually and more than 125 million girls and women alive today have undergone FGM in the 29 countries in Africa and Middle East where it is concentrated.
In July 2015, City University London published a report entitled Prevalence of Female Genital Mutilation in England and Wales. This builds on an interim report (published 2014) which estimates the number of women and children in England and Wales living with the consequences of FGM to be 137,000, with a further 60,000 born to mothers who have undergone FGM. This assumes that the women who have migrated are typical of women in their country as a whole.
In Somerset, there are an estimated:-
- 644 women permanently resident in Somerset (at the time of the 2011 Census) born in FGM-practising countries
- 54 women in Somerset with FGM
- 28 ‘maternities’ in the period 2005-13 to women with FGM, of these maternities, 16 were girls.
Since September 2014, acute hospital providers in England must now provide monthly data on the incidence of FGM including women who have been previously identified and are currently being treated (for FGM related or non-FGM related conditions as at the end of the month) and newly identified women within the reporting period.
- The active caseload for the whole of the South of England is currently 247 (at March 2015). There are no reported cases by either of the two hospital trusts within Somerset but there may be instances not known to either the police or NHS.
- More details about the new Enhanced FGM dataset are available on the Health and Social Care Information Centre (HSCIC) website. Quarterly data will be published, starting in September 2015.
See also our section on Safeguarding Children.
Relationship and Sex Education
The UK Youth Parliament Advisory Group (April 2013) believes that early sex and relationship education would help children understand themselves, their development, prepare them for growth and help them form positive identities. In turn, this will help protect them better and enable them to make better choices. This could be implemented through school, but should also be done at home and supported in the wider community too. In addition, secondary schools need to have much better and more consistent/effective sex and relationship education, support and advice available.
The Department for Education (2015) wants all schools to put high quality PSHE at the heart of their curriculum. It recognises that age-appropriate Relationships and Sex Education (RSE) is essential in keeping children and young people safe and healthy, and can provide them with the information they need to stay safe and build resilience against the risks of exploitation.
The Children and Social Work Act 2017 made Relationships Education mandatory in all primary schools and RSE mandatory in all secondary schools with effect from September 2019. The Department for Education have consulted on the scope and content of Relationships Education and RSE and consideration of PSHE and the results and new guidance are due for publication in September 2018.
Concerns have regularly been raised nationally about the quality of PSHE provision, by Ofsted and others, often focused on the lack of priority given to the subject and the level of expertise available in PSHE teaching. To support schools in developing and delivering a whole-school approach to PSHE Public Health at Somerset County Council (SCC) has partnered with experienced youth charity LIFEbeat to provide PSHE teacher training programme for Somerset primary, middle, secondary and special schools. More information can be found at www.cypsomersethealth.org
Somerset-wide Integrated Sexual Health service (SWISH)
‘SWISH’, a new service aimed at improving sexual and reproductive health in Somerset launched in April 2016.
Somerset Partnership NHS Foundation Trust through Swish provide a range of services including all forms of contraception and emergency contraception, pregnancy testing, diagnosis and treatment of sexually transmitted infections, HIV testing, chlamydia screening and advice on sexual abuse and abortion services.
As part of Swish the Eddystone Trust provide HIV prevention, targeted sexual health promotion and outreach services and condom distribution schemes in addition to the support services they already provide in Somerset for people living with HIV. This will include the promotion of early HIV testing and delivery of HIV rapid results point of care testing in the community.
A new sexual health website has been developed for Somerset which provides information on contraception and sexual health as well as details on clinics and opening times across Somerset. It will enable users to access it from any device and includes smart features like being able to call the service direct from the site if using a smart phone and will include the ability use Google maps and Google translate.