Select Committee on Health Appendices to the Minutes of Evidence


Evidence submitted by fpa (formerly the Family Planning Association) (PH 92)



  Sexual health is a key public health issue. In the twentieth century the great innovations in sexual health including:

    —  universal free contraception;

    —  open access specialist services to treat STIs; and

    —  the 1967 Abortion Act.

  Took their place alongside other major public policy measures which promoted public health. It is easy to forget that in the 1960s illegal abortion was widespread, with many women being admitted to hospital after unsafe operations, and that a number of these women died. For the hundreds of women unable to obtain contraception, the fear of unwanted pregnancy dominated their lives and inhibited their relationships. Today major public health issues still confront the UK, including the impact of HIV and AIDS, high levels of teenage pregnancy and the increasing level of Chlamydia infection, which all too often brings with it the misery of pelvic inflammatory disease, ectopic pregnancy and infertility.

  Yet sexual health is frequently seen as a private or life-style issue rather than being a mainstream public health issue. In our modern pluralist society, the life-style approach to sexual health recognises that:

    —  it is unacceptable for any one section of society to impose their values on others;

    —  sexual health can only be achieved if people are able to make informed choices; and

    —  appropriate services are available to support them in so doing.

  However, the ability to make an informed choice and to access services is affected by behavioural, emotional, social, economic and political factors, making sexual health a very significant aspect of public health as a whole.

  Achieving and sustaining individual sexual health requires high levels of emotional intelligence defined as "the ability to recognise and name feelings as we experience them, and to acknowledge the impact they have on our actions and on others". Emotional intelligence is central to the public health imperative of strengthening individuals and strengthening communities. It is fundamental to strategies to counter inequalities and social exclusion. Sexual health is vital for good relationships, and good relationships provide a basis for confident engagement with community, civic and social life.


  Sexual health, the capacity and freedom to enjoy and express sexuality without exploitation, oppression, physical and emotional harm, is central to every individual's physical and mental well being. There is a wealth of qualitative and quantitative evidence which shows that sexual health in the UK is poor.

  The capacity and freedom to enjoy and express sexuality requires a social climate in which it is possible to be open about sex. Such a climate does not exist in the UK. While the situation has improved since the first HIV awareness campaigns, many aspects of sex and sexual health are still affected by taboos. Examples abound and include the negative publicity surrounding the abolition of Section 28 (in England and Wales) and Section 2a (in Scotland) and the coverage of the licensing of hormonal progestrogen emergency contraception for pharmacy provision.

  In addition, overall indicators of sexual health show a very worrying position:

    —  the UK has the highest rate of teenage pregnancy in Western Europe;

    —  approximately one fifth of all pregnancies ends in abortion;

    —  a sixth of couples seek assistance for infertility;

    —  the number of new HIV infections in the UK increased by 6 per cent between 1998 and 1999;

    —  there were nearly 590,000 new cases of STIs diagnosed in GUM clinics in the UK in 1998—an overall increase of 6 per cent; and

    —  chlamydial infection in the UK is increasing rapidly, especially amongst young women.

  Sexual health is both a human and a social right which is essential to the exercise of full citizenship. It is also the basis for enhancing individual and community health and well-being through the promotion of the healing and creative power of sexuality. These figures demonstrate the current deficit in sexual health and the urgent need for action.


  There is currently a lack of data to build a comprehensive picture of the range of inequalities in sexual health. However, there are significant examples of inequality. For example, the relationship between teenage pregnancy and low socio-economic status and low educational achievement is well documented and illustrates the disadvantaged position of groups of young women. The needs of boys and men are also not adequately recognised so they are not met by sexual health services.

  There is a particular stigma attached to aspects of sexual health, for example HIV, other sexual transmitted infections and abortion, and to certain groups especially vulnerable to sexual ill-health. This stigma brings an added dimension to inequality.

  Homophobia is a major contributor to the inequality experienced by gay men and women, whose sexual health is often affected by oppression or physical or emotional harm. They have difficulty accessing appropriate sexual health advice from both primary care and specialist providers. Generic health promotion does not meet their needs and leaves them vulnerable to poor sexual health.


  Currently, sexual health services are fragmented and of variable quality. Few arrangements are based on a systematic needs assessment. Access is often limited through either insufficient provision or restrictive policies. The main issues at local level in each of the major areas of provision are:

Contraceptive advice

  In Britain, the majority of consultations about contraception take place in General Practice. GPs receive an additional fee for providing this advice to women, but not to men, regardless of their knowledge or training. Many GPs do not offer the thirteen different methods of contraception but concentrate on providing hormonal methods. GPs are not usually funded to provide free condoms to prevent pregnancy and reduce sexually transmitted infections.

  There are a number of high quality nurse led clinics yet, in general, nurses are underused in the provision of contraceptive advice. Extending the power to prescribe to appropriately trained nurses has been discussed for 20 years but the necessary legislation has yet to be put in place.

  Ignorance about the full range of methods is widespread, not only among members of the public but also among primary care professionals. As a result, many women are denied the opportunity to make an informed choice about the method which would suit them best. Choice is also restricted by budgetary limits on methods that are initially more expensive. However, research shows that for every £1 spent on contraceptive services there is a saving of £11.

  For many years it has been Government policy that women should be able to seek contraceptive advice from a GP other than their own or from a Community Clinic. However, this choice is not always available; there are many areas without local clinics or where access to clinics is limited to younger women.

Emergency Contraception

  Awareness of emergency contraception and the time scale within which it should be used is very high amongst potential users. However, there are frequently major barriers to using it, including difficulty in getting a timely appointment with a GP or other provider and, in some cases, professional ignorance or prejudice about its use. Whilst the availability of emergency contraception from pharmacists will increase access for women who can afford it, the majority of these barriers will still remain.


  Although abortion has been legal in England, Scotland and Wales under the terms of the 1967 Abortion Act for over 30 years, many women still experience major difficulties in obtaining an NHS abortion. Problems encountered include waiting times for appointments with their GP, or once referred, with an abortion provider, the attitude of their GP to abortion in general or to their particular circumstances and their health authority's policy towards providing NHS funded abortions. In 1998, the percentage of NHS funded abortions varied from 95.8 per cent in the best authority to 44.5 per cent in the worst. It would never be suggested that a woman should have to seek private maternity care because she does not meet local criteria for an NHS birth, but this is frequently the case for abortion.

  There is also considerable variation in the method of abortion provided in the early stages of abortion. Medical abortion for use up to nine weeks of pregnancy has been available in this country since 1991. Yet in 1998, the number of medical abortions as a percentage of all pre-nine weeks abortions varied from 58 per cent in the Northern and Yorkshire region to 5.4 per cent in the West Midlands. Furthermore, in some services the rate is as high as 75 per cent. While not all women wish to have a medical abortion, it is cheaper and has less risks associated with it than surgical abortion. Many women are being denied this option.

  Women in Northern Ireland face even greater barriers than those in the rest of the UK. While some abortions are carried out in Northern Ireland, the majority of women seeking abortion have to travel to Britain. As a result, they tend to have abortions later in pregnancy which means increased risk. They also face considerable expense and disruption to their lives.

Sexually transmitted infection

  Many people seek advice about sexually transmitted infections in the first instance from their GP. As with contraceptive advice, GPs vary in their expertise in this area. They are not required to keep any record of the number of consultations for sexually transmitted infections, so unlike contraception, information is not available about the number of these consultations taking place each year within general practice.

  Every health authority area has a self-referral provision for the diagnosis and treatment of sexually transmitted infections. However, in many areas pressure on these services is so great that there are serious delays in obtaining appointments.

  Currently, there are pilot schemes in operation in Portsmouth and the Wirral, where screening for Chlamydia is being offered to young women in primary care, family planning, sexual health and antenatal services. The results of these studies should be published shortly.

  Public awareness about Chlamydia and its potential consequences for women's health is limited although increasing. However, many women are falsely reassured by the belief that when they have a cervical smear, they are also being screened for sexually transmitted infections.


  At national level, fpa is funded to provide the Contraceptive Education Service in England, Scotland and Northern Ireland. This is a comprehensive service with a helpline and information service for the public, professionals and the media, information leaflets on contraceptive services and methods and a specialist library and information service for professionals. It handles over 100,000 inquiries a year. As a result, fpa has a unique overview of sexual health provision as experienced by both the public and professionals.

  Although styled as providing information about contraception, the service covers all aspects of sexual health including contraception, conception, infertility, early pregnancy, abortion, sexually transmitted infections and sex education. During 2000 a directory of all UK clinics which offer sexual health, including contraceptive advice, has been created on fpa's website. The service also acts as a gateway to other sources of information and advice.

  The service receives many calls from women who are uncertain about how they wish to respond to an unintended pregnancy and who have been unable to locate a service to help them decide what to do. Currently, the service is not resourced to respond fully to these calls.

  The Contraceptive Education Service has worked closely with NHS Direct, looking at the relationship between the specialist and the generalist helpline. We envisage that as the public's awareness and use of NHS Direct increases, it will deal with routine enquiries, allowing fpa to focus on those where its specialist expertise is essential.

National Campaigns

  National campaigns have played a significant role in increasing public awareness of sexual health issues. For example, there have been a number of campaigns about emergency contraception and more recently, there has been a focus on chlamydia. While individual campaigns do not lead to immediate changes in behaviour, they do provide vital information and increase awareness without which behaviour change is unlikely.


  Differing views within society about sex and sexual morality make sexual health a sensitive area for public policy. The Government should be applauded for legislating to equalise the age of consent for gay men and for attempting to repeal Section 28. However, in other key areas, notably abortion, they have done little. The vociferous anti-choice minority has powerful allies in sections of the popular press. Without a strong Government voice in support of women's rights within existing law, abortion will continue to be marginalised within the NHS. Many girls and young women develop anti-abortion attitudes without ever having had the opportunity to consider the issues fully. As a result, if they have an unintended pregnancy they are unable to make an informed choice for the future.

  The Government is currently developing a Sexual Health Strategy which will provide the framework for sexual health services in the future and will, we hope, address the many urgent matters raised in this paper. A successful Strategy must bring together the two key aspects of sexual health, individual choice and collective responsibility, if it is to meet the diverse needs of a varied population. The draft Strategy is eagerly awaited for consultation.

  The Government has also put in place a comprehensive programme to reduce the number of conceptions amongst under 18s and to provide better support to teenage parents. The programme is still in its early stages of implementation. fpa welcomes its co-ordinated approach. However, we believe that the Government will only be successful in achieving its objectives if efforts to reduce teenage pregnancy and support teenage parents take place within the broader context of promoting young peoples' health, including their overall sexual health.

  Sex education has been clearly identified as a significant component of the programme. While the Sex and Relationship Guidance issued by the Department for Education and Employment in July 2000 is a great improvement on previous guidance, it is equivocal and ambiguous in a number of important respects. In particular, it does not provide the necessary support to primary schools to ensure that children receive clear information about sex and relationships at an early age instead of absorbing confused messages from the media and their peers.


Encouraging a more mature attitude to sex

  It is vital that the Strategy addresses ways of creating and fostering a climate of opinion which encourages responsible discussion about sex, sexuality and sexual health. A more supportive climate of openness would enable parents, carers, teachers, social workers, health professionals, youth workers and all other relevant professionals to feel more confident about talking to children about sex. It would also encourage people of all ages to seek the advice, help and support they need. The climate of opinion will be crucial to the success of the Strategy because of its influence on the ability of individuals, communities and the government to take the actions needed to achieve results. The media plays a significant part here. It is essential that steps are taken to maximise the positive aspects of the media's role.

Sexual health as a mainstream issue

  Sexual health is often "marginalised" in relation to other aspects of sexual health. This not only contributes to the negative social climate described above but can also have an impact on local decision making about service provision and professional training which may be discriminatory, judgmental or ill-informed. If sexual health is to be fully addressed, it is necessary to involve the broad range of professionals whose role encompasses aspects of sexual health, even if they do not see themselves as "sexual health" professionals.

Quality services

  The standard of all sexual health services varies enormously from the outstanding to the dreadful. Far too many people seeking advice are being failed by services which are not sufficiently sensitive to their circumstances. The range of services must be sufficient to meet the needs of the general population as well as marginalised and hard to reach groups. Staff must be non-judgmental, sympathetic and well-informed.

Professional training

  Working in sexual health requires particular skills and competencies. In addition to clinical and technical ability, communication skills and sensitivity to different cultures and attitudes are central. These areas need to be addressed in both initial training and in continuing professional development. Sufficient resources must be made available to ensure that the necessary training is provided.

  Training for teachers and others providing sex and relationships education in schools is a major priority. Lack of a sufficient number of trained staff is the most significant barrier to the provision of effective sex education. The Department for Education and Employment should make this a priority area and allocate the necessary resources to it.


  The sensitive nature of sexual health makes confidentiality crucial for many service users but this is an area where there is a great deal of confusion. The Teenage Pregnancy Unit is addressing the issues as they affect young people. However, the needs of other service users must not be overlooked.

  Clarification is required for all professionals who work within sexual health. Clear information needs to be effectively disseminated and well understood by professionals. Confidentiality obligations should be incorporated into quality standards and professional training. Every service should have a policy about confidentiality which accords with professional codes of practice. The policy should be explained to service users and potential users.

NHS structures

  Organisational and structural divisions within and between specialist and generalist services frequently act as barriers to the provision of effective services. Joining up the range of sexual health services—pregnancy testing, contraception, abortion, emergency contraception, genitourinary medicine, HIV/AIDS, the sexual health aspects of primary care and health promotion—is made more difficult than it should by different commissioning arrangements and funding mechanisms and clinical "turf wars". The fact that genitourinary medicine, family planning and abortion services may be in different NHS Trusts exacerbates the difficulties and works against effective integration of services to meet user needs.

  The introduction of Primary Care Trusts provides an opportunity to improve the situation. PCTs will need to have sufficient expertise and commitment to realise their potential in this area. Government recognition of and support for this aspect of their role will be essential. PCTs should have responsibility for ensuring a comprehensive sexual health service is available in their area. They should undertake a full needs assessment and review the range of professional skills and services available to meet these needs. Duplication and gaps in provision should be identified and a strategy developed to remedy them either by changes in existing services or by allocating additional resources. Each PCT should ensure that national evidence based quality standards underpin the services provided in its area and that confidentiality and choice is protected.

Research and data collection

  While there is excellent data collection on some aspects of sexual health, in other areas there is a paucity of data as the basis for policy and service development. Monitoring and surveillance in sexual health is currently disadvantaged by the separate collection of data on different outcomes (conceptions, births and abortions, sexual transmitted infections, HIV and AIDS) and the lack of compatibility between them. The development of positive, non-disease or pregnancy-focused indicators could provide a means of monitoring the success of measures to improve sexual health which looks beyond the mere absence of negative outcomes.

Information provision

  There is still considerable ignorance amongst all age groups about sex and sexual health. Therefore, the provision of unbiased, authoritative information, in a variety of formats, is essential. Research with service users repeatedly confirms that they value the advice they receive from a sexual health professional being backed up by written information that they can refer to after the consultation. The provision of such information should form part of the quality standard for sexual health services.

  Experience with the Contraceptive Education Service shows that a national charity can be a very effective provider of information both in terms of quality and cost effectiveness. Each year the demands on the Service rise, in terms of both the quantity and content of inquiries. It has expanded its expertise as far as possible within existing resources to meet these needs. In the future, we would like the Service to be funded so that it can provide coverage of all sexual health issues and meet the needs of specific groups such as women facing unintended pregnancies.

National campaigns

  There is considerable uncertainty about how national sexual health campaigns are to be undertaken in the future. Yet these have an important part to plan in raising public awareness of issues and over the longer term, in influencing behaviour.

  The Health Education Authority had a sexual health team with considerable expertise which provided back up to the major national campaigns funded by the Department of Health. That team has been disbanded and now the only similar groupings are within the small number of national sexual health voluntary organisations. Although there is considerable capacity within the Department of Health to commission campaigns, in general it is more effective for campaigns to be undertaken by organisations that have specific expertise in the area concerned so that follow up over a long period can take place.

  There is an urgent need for further campaigns on a number of aspects of sexual health such as sexually transmitted infections. A campaigns strategy needs to be developed and funded. Such a strategy should utilise the knowledge and strengths of the national sexual health organisations.


  Sexual health is a neglected area of Public Health where policy development has all too often been led by high profile media issues rather than the needs of the population. As this paper demonstrates, the present unsatisfactory state of sexual health in the UK and the uneven quality of sexual health services means that action is urgently required so that adequately funded, integrated provision is available.

  fpa welcomes the Government's decision to develop a sexual health strategy but we are concerned that the draft has not yet been published for consultation. We urge the Committee to impress on the Government the need for immediate publication.

January 2001


  The Economics of Family Planning Services, A McGuire and D Hughes, fpa 1995.

  The fpa's Guide to Commissioning Sexual Health Services, fpa 1998.

  fpa's Guide to Commissioning Sexual Health Service for Young people, fpa 1999.

  Individual Choices, Collective Responsibility: Sexual Health, A Public Health Issue, Maria Duggan and Anne Weyman, fpa 1999.

  Sexual and Reproductive Health and Rights in the UK: Five Years on from Cairo Anne Weyman, Marge Berer and Amy Kapczynski, fpa 1999.

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