Sexual Health and Blood Borne Virus Framework 2015-2020 Update

Sexual Health And Wellbeing

Introduction

As reflected in the original Framework document sexual health and wellbeing is a broader subject than the other topics within the Framework, and there are areas where progress is needed across all age groups and risk groups. We need to continue work to minimise risk-taking behaviours and consequences, and to promote positive sexual relationships and wellbeing. There are significant emerging issues around coercion and harm and the influence of new technology and social media. Awareness of and reduction of sexual exploitation and harm should be core priorities for all organisations and agencies.

Key Progress

• In November 2011 Healthcare Improvement Scotland (HIS) published an overview report on its review of sexual health services in Scotland against the HIS sexual health standards^[7]. This report found that Boards had made significant progress in raising the profile of sexual health services; in improving the individual patient experience; and in providing more suitable accommodation for clinics.
• There is a differing pattern emerging regarding acute STIs in Scotland during the past four years; diagnoses of some sexually transmitted infections have increased while those of others have declined or stabilised. Evidence suggests that the incidence of STIs among young heterosexuals and MSM through unprotected sexual intercourse remains a problem in Scotland; challenges for control and prevention of STIs continue.
• There have been increases in the use of longer-acting reversible methods of contraception (LARC) across Scotland. The uptake of very long acting methods (the contraceptive implant, IUDs (the coil) and Mirena® (IUS)) in Scotland increased from 56.7 per 1,000 women aged 15-49 in 2009/10^[8] to 62.1 per 1,000 women in 2013/14^[9]. However, there is still variation in provision across Scotland which must be improved.
• The rate of teenage pregnancies in Scotland have been in decline since 2007 and are the lowest they have been since at least 1994^[10].
• A modelling study on the cost effectiveness of chlamydia screening in Scotland, funded by the Scottish Government, was published in January 2015^[11]. The study concluded that the current chlamydia testing strategy in Scotland is not cost-effective under the conservative model assumptions applied. However, with better data enabling some of these assumptions to be relaxed, current coverage could be cost-effective.
• The Scottish Government national awareness raising campaign on sexual health ('Sex: It's Healthy To Talk About It') led to an increase in numbers of people accessing online information about sexual health. There have been over 168,000 unique visitors and over 192,000 visits a year to the website.
• Over the past five years there has been a reduction in the number and rate of terminations of pregnancy carried out in Scotland, with 11,777 carried out in 2013 compared to 13,904 in 2008. In addition the proportion of early terminations has been rising steadily in recent years, with 69.2% of all terminations performed at less than 9 weeks in 2013, in line with HIS Clinical Indicators, compared to 62.2% in 2009^[12].
• The Scottish Government has funded the establishment of a Sexual and Reproductive Health post within Scottish Drugs Forum to provide training to staff working in sexual health services and drugs services on the links between sexual behaviours and drug and alcohol use.
• The Scottish Government funded the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow to undertake research on how sexual health and BBV issues are reported in the media.^{[13],[14],[15]}
• The Scottish Government commissioned and published the findings from a sexual health and wellbeing survey in 2014.^[16] This provides a baseline for future monitoring of change in the general population on specific topics and identified some sexual wellbeing themes as needing closer consideration.
• The Scottish Government funded Brook to develop the "Sexual Behaviours Traffic Light Tool"^[17] to assist those working with young people to have an awareness of normal childhood sexual behaviour.
• The Scottish Government funded NHS Lothian to undertake research comparing the delivery of abortion care in hospital settings versus the community^[18].
• The Scottish Government funded researchers at the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow to undertake research into people who present very late (after 19 weeks 6 days) for terminations in order to improve care for these individuals^[19].

Key Developments

• The Smith Commission on the devolution of further powers to Scotland recommended that a process be established to consider the devolution of powers relating to abortion (amongst others).
• In December 2014 the Scottish Government published updated statutory guidance on the conduct of Relationships, Sexual Health and Parenthood (RSHP) Education in Schools. This revised guidance reflected the need for discussion of all types of relationships as part of RSHP education to acknowledge that, as a result of the Marriage and Civil Partnership (Scotland) Act 2014, both opposite sex and same sex couples can marry. The guidance also made explicit links to the Sexual Health and Blood Borne Virus Framework.
• The Scottish Government's Children and Young People (Scotland) Act 2014 was passed, setting out a number of new duties on public authorities in Scotland. The Act, which is at various stages of implementation, is central to the Scottish Government's aim of making Scotland the best place in the world to grow up by putting children and young people and their wellbeing at the heart of the planning and delivery of services and ensuring their rights are taken into account across the public sector. In particular Part 3 of the Act - Children's Services Planning - emphasises the importance of prevention and early intervention, which is relevant to work with young people in relation to sexual health.
• Findings from the third National Survey of Sexual Attitudes and Lifestyles (NATSAL-3) were published during 2014^[20] with findings from Scotland published in March 2015.^[21]
• Significant public and media interest has occurred in relation to child sexual exploitation and historic sexual abuse resulting in an increased need for clear information and messages for young people, parents and those supporting them.

• The emergence of new psychoactive substances in recent years gives rise to a number of issues relevant to the Framework, including the work of IEP services and the risks associated with injecting of NPS, but also the increased potential for risk-taking behaviours amongst individuals while using NPS.

Key Priorities

Prevention

Prevention remains a fundamental principle for all parts of the framework. In the context of sexual health this means: supporting good relationships and sexual health, and preventing poor sexual health and resultant sexually transmitted infections and/or unintended pregnancies. The implementation of Relationships, Sexual Health and Parenting (RSHP) education is key to ensuring all young people across Scotland have the information and skills to make healthy choices regarding their sexual health. Given the disproportionate and rising burden of HIV and STIs in MSM, especially young MSM, it is important that all RSHP is inclusive.

The implementation of RSHP education in schools is the responsibility of Directors of Education, and the Scottish Government issued updated statutory guidance in December 2014. NHS Boards and Third Sector organisations can support the delivery of education by building links with schools and local education departments. A strategy in supporting this work is to emphasise the important issues of child sexual exploitation^[22], coercion, gender-based violence and healthy relationships. All schools should recognise the importance of informing and educating children on these important topics, particularly in relation to younger and vulnerable children (including looked-after children).

RSHP education is important in making progress on issues relating to teenage pregnancy and young parenting, and the Scottish Government's new Teenage Pregnancy and Young Parent strategy will provide more detail on these issues. However the development of the strategy has already involved significant consultation with young people across Scotland. This has highlighted that young people are looking for more information on relationships and more comprehensive RSHP education in schools. Young people have also said they would like more input into the curriculum on these subjects. There remains a challenge in ensuring that young people are able to access sexual health information and advice in schools and public buildings (libraries etc.) and that these are not subject to restrictions/filters.

Local Authorities/Directors of Education, NHS Boards and Third Sector partners should continue to work together to support high quality, consistent and inclusive RSHP education in all schools across Scotland. RSHP education should continue to be provided to all young people in all schools and wherever learning takes place, with delivery in line with equality and diversity legal obligations.

Teaching staff delivering RSHP education should be trained to ensure they have the necessary skills, attitudes and confidence. NHS Boards and Third Sector partners can support such training and can make links to services for young people.

Local Authorities, supported by NHS Boards and Third Sector organisations, should ensure they provide support to parents and carers on improving communication between them and their children on RSHP issues.

Young people should be involved in the design of local approaches to teaching of RSHP.

These issues will be articulated through the new Pregnancy and Young Parents Strategy, and that Strategy will also set out responsibilities on monitoring and reporting on progress of these actions.

The Scottish Government's sexual health campaign: Sex: It's Healthy To Talk About It encourages adults to have conversations with their partners about all aspects of sex and relationships. This aimed to increase confidence, reinforce the importance of negotiation and boundaries as well as empowering people to have healthy and fulfilling relationships.

Given the importance of continuing to have reliable, accurate information available the Scottish Government will continue to fund the 'SexualHealthScotland' website, which remains the go-to place for sexual health and relationship information in Scotland. We will give consideration to whether Sex: It's Healthy To Talk About It should be strengthened or refreshed or whether a higher profile campaign approach would bring benefits in reaching specific audiences such as young people. Services also need to consider how they can increase the number and quality of conversations about relationships and good sexual health in response to the needs of the public.

Contraception

In 2013 NHS Lothian established a pilot project to look at the viability of providing post-partum contraception universally. The 'APPLES' (Accessing Postpartum LARC in Edinburgh South East) project looked at improving access to contraception for postpartum women, with particular emphasis on the most effective (longer acting reversible or 'LARC') methods. The study integrated contraceptive advice and supplies of women's chosen contraceptive method into maternity care, envisaging that this might prevent future unintended pregnancies for women and give women more control over inter-pregnancy intervals. Inter-pregnancy intervals of less than a year have been proven to increase risk of stillbirth and neonatal death, and it has been shown that a significant number of women have a repeat pregnancy within one year of giving birth. Therefore it is important that services recognise that all women are entitled to access contraception, not just those judged to have specific risk factors for repeat pregnancy.

The pilot is on-going, but initial positive findings were presented to the Ministerial Advisory Committee in late 2014. In light of this, and the potential benefits of an approach of integrating the provision of post-partum contraception into perinatal care, NHS Boards should roll-out this approach, ensuring that all women have the opportunity to be counselled antenatally regarding postnatal contraception and to be provided with their preferred choice of contraception, or a bridging method, in maternity services across Scotland prior to discharge following delivery or immediately after where feasible - the six week check-up can be too late for some women. This will make it easier for women to access contraception in a patient-centred way. The potential challenge to implementation of this project relates primarily to the training of maternity staff. Therefore the Scottish Government will support training costs for maternity staff including community midwives and health visitors for the purposes of implementing this approach.

The provision of contraception directly after termination of pregnancy is also an important approach to preventing repeat unintended pregnancies and increasing ease of access to contraception for those women who wish it. NHS Boards and services providing termination of pregnancy services should include information on contraception, and the opportunity for women to be provided with contraception if they wish it, as soon as possible post termination as a core part of abortion care.

While the provision of longer acting reversible contraception has led to reductions in unintended pregnancies and terminations, the same impact has not been seen in relation to sexually transmitted infections, and condom promotion and distribution continues to be important.

Emergency Hormonal Contraception will continue to be available free of charge through community pharmacies in Scotland.

Abortion

The Smith Commission on the further devolution of powers to the Scottish Parliament recommended the establishment of a process to consider the devolution of legislative powers on abortion. The Scottish Government is in discussion with the UK Government on this issue.

In order to improve health outcomes the majority of abortions should be carried out before 9 weeks gestation.^[23] NHS Boards should continue to develop pathways so that as many abortions as possible are carried out early in pregnancy and that unnecessary delays at all stages are minimised. Boards should however ensure the appropriate support and services are available for the small number of women who present very late (after 19 weeks 6 days) for abortions.

The number of repeat terminations in Scotland still remains high with around a third (30.7% in 2013) having had at least one previous termination in their lifetime (but not necessarily in quick succession). Research is being carried out by the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow into the reasons why women seek multiple terminations. The results of this study will inform future work.

Inequalities

Inequalities are relevant to all aspects of sexual health work, and approaches discussed in the original Framework, and elsewhere in this chapter, will contribute to tackling inequalities specifically (e.g. access to contraception) and more generally (education and awareness raising).

There are a number of groups who may be particularly disadvantaged in respect of sexual health, including looked-after and accommodated children and young people; prisoners; MSM and individuals involved in commercial sexual exploitation. Often these people will have multiple needs and risks, including alcohol use and poly-drug misuse. The Scottish Government funded a Sexual and Reproductive Health post within Scottish Drugs Forum (SDF) to support the further development of links between sexual health and addictions services, focussing on the needs of vulnerable groups. This has been an important capacity-building post so the Scottish Government will continue to fund this post until at least 2017 to allow this important work to continue and develop.

In addition to this specific post there are opportunities for greater links between Alcohol and Drug Partnerships and sexual health services. The SDF post has started to address this in some local areas and the Scottish Government will support work to continue to build on this, complimenting the Scottish Government's work to increase the capacity and effectiveness of alcohol and drug partnerships. A range of local and national interventions will be used to embed work in this area into the core business of local partnerships.

Chlamydia

Scotland's Chief Medical Officer (CMO) previously established an expert group to examine the evidence for chlamydia testing policy in Scotland, and that group reported to the CMO in 2014. The group's report recognised the significant uncertainty that exists around the clinical implications of chlamydia infection and the cost effectiveness of different screening or testing approaches, and therefore recommended that a cost effectiveness study be undertaken on chlamydia testing policy in Scotland. The Scottish Government commissioned this work via Health Protection Scotland and the results were published in January 2015^[24].

Scotland does not have a national chlamydia screening programme; rather NHS Boards are responsible for testing for chlamydia in line with existing clinical guidelines^[25]. In light of the cost effectiveness study findings, the Scottish Government will work with the Scottish Intercollegiate Guidelines Network to make any necessary updates to existing guidelines on the management of chlamydia. NHS Boards will continue to be responsible for delivering chlamydia testing in their own areas, in line with National Guidelines and local needs and priorities.

Treatment/services

NHS Boards should continue to ensure that sexual health services are provided in line with Healthcare Improvement Scotland sexual health standards. Sexual health services should be high quality and designed to meet the needs of patients, including young people and vulnerable groups.

It is important that sexual health services do not operate in isolation. The links between poor sexual health, addictions, alcohol use and other vulnerabilities are apparent. Sexual health services should have good quality links with addictions, mental health and other services, and service planners should be mindful of the need to provide holistic services to patients. For example, Scottish Drugs Forum work with addictions services highlighted that very little sexual and reproductive health work was being undertaken by these services. In most cases, questions were not even being asked of clients regarding issues of sexual and reproductive health. This led to the Scottish Government-funded work with SDF to train staff on the links between addictions and sexual health. This work will continue to be funded by the Scottish Government, but local planners should also consider these issues as part of their core responsibilities.

Emerging evidence (including from NATSAL and the recent MSM HIV Prevention Needs Assessment) is telling us that staff in services beyond core sexual health services may not be comfortable with or confident in discussing important sexual health risks and issues, including with young people. This requires us to increase efforts to enable a wide range of staff to have frank discussions with anyone who is or may be sexually active about sexuality (including young people and older people), all forms of sexual behaviour, consent, pleasure, rights and safety in a sexual context. The Scottish Government will work with the NHS Executive Leads to determine whether there is work that could be done nationally to develop core educational materials or information resources for staff in specialist and non-specialist services.

Coercion and harm

Coercion and harm related to sexual relationships is a particularly important issue of which all health staff should be aware. This issue is relevant to sexual relationships at all ages, and to the issue of violence against women and girls.

NATSAL 3^[26] data reported an increase in reports of anal sex in young heterosexual men and women, and subsequent research illustrated the coercive circumstances in which this often occurs^[27]. There were also reports of non-volitional sex in the same research and in the Scottish Government's 2014 survey on sexual health and wellbeing. Education and awareness-raising are part of the solution to these issues, but will never be the entire solution. Services, parents, teachers and carers need to be able to provide support and advice to service users and to those who do not access services (including understanding of why services are not being fully utilised)

At the extreme end of coercion and harm, childhood sexual exploitation is a subject where there has been much public and media debate in the last few years. The links to sexual health and other NHS services in Scotland are important, and again the role of education and awareness-raising of healthy relationships is vital.

There has also been much concern expressed across Scotland regarding the impact of social media and the facility for sexual expression through communication technology. This has transformed the lives of young people and the context in which they explore and express their sexuality and form relationships. Many sexual contacts are now managed on-line and there is increased use of pornography, especially by boys and young men. This is likely to have an impact on expectations around sex and relationships and their links to gender-based violence. There is the potential for harm and exploitation through the use of such technology and services need to be aware of these issues.

There are no simple solutions to these issues, but the NHS Executive Leads will continue to give consideration to the role of NHS services in helping to tackle coercion and harm. As a minimum, sexual health specialists should be involved in local multi-agency groups addressing child sexual exploitation to ensure that effective pathways and information sharing protocols are created. The Scottish Government will also ensure the necessary links are made to other policy areas within Government, and the National Monitoring and Assurance Group will consider what more can be done to improve the identification and interpretation of appropriate outcome indicator data as a first step to informing action.

Stigma

Longer term challenges remain in addressing stigma and homophobia, the impact of which may increase sexual risk behaviour and act as a barrier to sexual health and other service use.

A sexual health and blood borne virus media group is already in existence, chaired by Health Scotland. This group aims to support accurate reporting around the topic areas of the Framework. The group is working to develop a bank of expert speakers from the NHS, who can be available to support reporting and media activity. This activity is intended to be a mechanism to provide positive contributions to media reporting. This work will continue. In addition, NHS Boards and local partners should consider how to challenge stigma and prejudice locally through their local action plans.

Sexual dysfunction

Surveys and research conducted during the first four years of the Framework have shown that sexual dysfunction can have a significant impact on their quality of life for many people. The Scottish Government's 2014 survey found that 23% of respondents had a health condition that had affected their sexual activity in the previous year and that 22% of men and 19% of women had avoided sex in the previous year because of sexual difficulties. (This was considerably more than the NATSAL sample which was 11% of men and 13% of women). This is an issue for people of all ages, however many services focus on younger people only and do not fully consider the needs of an ageing population who are sexually active into older age.

Good sexual health is not only about reducing disease but also about improving sexual wellbeing. Services need to be aware and willing to have discussions with people about their sexual wellbeing and referral into treatment for sexual dysfunction where appropriate should be provided. In addition it is vital that 'normal' healthy relationships are promoted to reduce inaccurate perception of dysfunction.