Lanarkshire Sexual Health Strategy

Lanarkshire Sexual Health Strategy

and

Action Plan

2005-2008

A strategy and action plan to promote positive

sexual health, in all its dimensions, for the people of Lanarkshire in a way that is equitable and nonjudgemental, and sensitive to individual needs.

Final draft

October 2006

The Lanarkshire sexual health strategy group consisted of representatives from;

NHS Lanarkshire

North Lanarkshire Council

South Lanarkshire Council

Terence Higgins Trust Scotland (formerly PHACE Scotland)

fpa Scotland

Church of Scotland

Diocese of Motherwell

Strategy

Acknowledgements5

Introduction6

Background6

Strategy group membership7

Vision for sexual health7

Definition of sexual health8

Model of sexual health9

Values and principles12

Setting the scene13

Wider influences on sexual health21

Range of services25

Priorities34

Links to other strategies and planning processes38

Communications38

Action plan38

Review and reporting mechanisms40

Action plan

Introduction42

Early years45

Teenage transition49

Workplace60

Community63

Clinical services plan80

Communication86

Overall action plan87

Membership of action planning groups89

References91

Appendix 1 Relevant strategies and policies for 92

sexual health promotion

Appendix 2 Report on sexual health strategy workshops94

Appendix 3 Strategy group membership101

Appendix 4 Mapping exercise of sexual health services 103

in Lanarkshire

Appendix 5 Current sexual health clinical services108

in Lanarkshire

Glossary115

Acknowledgements

We would like to thank all those who took the time to comment on the strategy and action plan during their consultation periods. The feedback we received was welcomed and helped to strengthen the document.

Thanks also to colleagues who commented on various drafts of this document and who provided support and information throughout the process.

We are also grateful to the Sexual Health Strategy Project Team from the Health Promotion Department, NHS Lanarkshire, for organising the consultation events, analysing the consultation feedback and producing the strategy and action plan.

Introduction

An individual’s sexual health affects their wellbeing as a whole and is central to some of the most important and lasting relationships that they will form. This makes promoting, protecting and nurturing the sexual health of the population a priority, not just for health service providers, but also for statutory and voluntary organisations, and the general public. It is crucial to involve this range of agencies to promote sexual health.

This importance is reflected in the raft of strategies, policies and frameworks that have been introduced in recent years. Appendix One lists some of these policies. While certain key groups, such as young people or gay men, have received particular attention due to their importance in public health, many more initiatives target an increasing number of populations, using a variety of methods, and involving a growing number of agencies.

Background

The current action in Lanarkshire on sexual health started with two, one-day workshops for key stakeholders in March and April 2002. Just under thirty people attended each workshop, representing education, social work, the voluntary sector, faith groups and health. The workshops acted as a useful starting point for developing the Sexual Health Strategy by allowing participants to share experience, learning, issues and ideas. The participants also agreed a set of values and principles during the two days, and these underpinned the work of the strategy group.

A summary report of the workshops appears in Appendix Two. Since then, the Scottish Executive published a national sexual health strategy group for Scotland (Scottish Executive, 2005). Here in Lanarkshire we have tried our best to make sure our strategy fits in with theirs. In particular, the Lanarkshire sexual health strategy group shares the view of the national strategy group that:

“for many people, issues around sex and relationships are founded in and inextricably linked to personal, societal, and faith-based morality. Interpretations of morality,however, vary from individual to individual, society to society and faith to faith. We do not, therefore, feel it is appropriate for this sexual health strategy to arbitrate on such matters. What the sexual health strategy can and must do is:

recognise and embrace the cultural, ethical and spiritual components which impact on an individual’s sexual health;
encourage and support individuals in developing and maintaining their own sets of moral values;
develop and promote services which are sensitive to and respectful of the diversity of beliefs, values and moralities which people bring with them.”

(Scottish Executive, 2003a; p2)

Strategy group membership

The strategy group has representatives from a range of public sector and voluntary organisations across Lanarkshire, as well as from faith groups. This reflects both the need for an inclusive approach and the fact that no one agency, profession, or service has “all the answers”. Ideally, we would have liked to have all appropriate parties represented on the group. However, we had to balance this full representation against having a number on the group that was workable. Appendix Three lists all group members and time served.

While all members of the strategy group may not agree with all aspects of the strategy, the process made sure the group heard and respected all views presented, and that people could access information and ideas about different approaches to sexual health.

Definition of sexual health

Sexual health is an important part of overall health. Being healthy is about feeling good physically, emotionally, socially and spiritually. When individuals are fully informed about all aspects of sexual health they are in a position to make the best decisions about themselves, their sexual partners and their sexual practice(s). For those choosing to be sexually active, sex should be enjoyable, safe and based on mutual respect and agreement.

This breadth and diversity is reflected in the World Health Organisation’s positive and holistic approach. They define sexual health as:

“A state of physical, emotional, mental, and social wellbeing related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

(World Health Organisation, 2002)

The Lanarkshire sexual health strategy group recognises this holistic and positive view. However, the group also supports the 1974 World Health Organisation definition of sexual health that incorporates “love” into the definition, as we believe this is also an important element of sexual health.

During discussions in the initial workshops, the multi-agency group also agreed that sexual health enables all individuals to feel empowered to be able to express all aspects of their own sexuality in a safer and informed way.

Sexuality is not seen in a restrictive way but is inclusive of a person’s psychological, physical, spiritual and social wellbeing.

Safer with the minimisation of harm, emotional and physical, or infection to those involved.
Informed where individuals can assertively agree on boundaries, choice, social responsibilities, what’s ok and what’s not.

Model of sexual health

As you have seen, the strategy group has adopted a wide-ranging concept of sexual health that places this aspect of health within a “whole person” approach. Acknowledging the importance of both social and medical models of health, we have come up with a model that combines them.

Figure 1: Model of sexual health

Each dimension impacts on the others, as signified by the outer circle, and each dimension is described below. Although specific groups (for example, people with a learning disability, black and minority ethnic communities) are not explicitly mentioned in each dimension, all areas interact and impact on an individual. Therefore, each dimension is relevant to a person or group, irrespective of their (individual) circumstances.

The ethical dimension refers to the widest meaning of a values and spiritual base on which people build their core beliefs. This dimension also incorporates the importance of advocacy for those who are not in a position to claim their own rights.

The psychological or emotional dimension covers mental and emotional wellbeing where it relates to sexual health. So this area includes the feelings and relationships aspects of sexual health, which is as important as the physical element of sexual health. For young people, this may mean developing emotional literacy, for example by learning to communicate their feelings with others. Issues around the experience of, or survival from, and therapeutic support for (sexual) abuse are also relevant here.

The physical dimension is about helping people to view in a healthy way reproductive health issues (including contraception and pregnancy planning) and those parts of the body involved with sexual activity, and to stay free from infection, and avoid unintended pregnancy and dysfunction.

The educational dimension includes all aspects of knowledge of sexual health and developing values from the home, through school and further education, as well as youth and other services, and lifelong learning throughout the community.

The social dimension refers to interpersonal relationships and the range of social skills people need to form positive relationships and to minimise negative influences ― for example the influence of peer pressure on people’s behaviour. The association between sexual ill-health and social inequalities is also covered here. For example, young women from the most deprived areas are three times more likely to become pregnant in their teens than those from the most affluent areas (Scottish Executive, 2003a). Barriers to positive sexual health in the social dimension are wide ranging, and include staff attitudes to sexual health service users and acceptability of gender-based violence.

The cultural dimension refers to the knowledge, attitudinal and behavioural factors in society around sex and sexuality. These (sometimes contradictory) factors surround individuals in all aspects of their life and can arise from families and the home, as well as from ethnicity, faith and social attitudes to diversity, disability and sexuality.

The legal dimension refers to Scottish, UK and international law as it relates to rights, responsibilities and sexual behaviour of people. Therefore, this part includes legislation on a range of matters, including age of consent, civil partnership, discrimination, diversity and equality.

The political dimension links to the influence, expectation, guidance and direction from the political world, locally and nationally as they impact on sexual behaviour. This dimension also encompasses support and advocacy work for groups that are marginalised, as well as working with local policy makers to ensure sexual health inequalities are addressed.

To develop positive sexual health it is important to work holistically across all the dimensions noted above, and to work with varying combinations of each dimension as needed. It also means being able to work at various levels, listed below, to specifically address issues, depending on circumstances:

individual ― working on a one-to-one basis, for example through outreach work or during individual consultations, some of which may be clinical.

interpersonal ― interventionsthat target couples, families and groups, both small and large, in relevant circumstances. This includes working to improve relations within families, or between partners and couples, as well as working in schools as part of sexual health and relationships education.

communities ― larger scale projects targeting groups with a common feature, which can be in terms of a location or characteristic. This includes making sure people from minority and marginalised groups can make better health choices through access to appropriate information and services that are sensitive to their needs. This level is also commonly used to target public health bloodborne virus work.

general public ― generic work that aims to communicate “healthy” messages as widely as possible. Sexual health messages can target specific issues, such as sexually transmitted infections, or can form part of a more general health campaign.

Values and principles

These were agreed at the initial workshops (Appendix Two) and show our strong commitment to individual rights, respect for diversity and commitment to a needs-led and inclusive strategy. The strategy is set within a context of social justice and adheres to human rights and legal frameworks.

The values and principles that underpin this strategy have at their centre the concepts of dignity, respect, equity, confidentiality, informed choice, inclusiveness, a non-judgemental approach and challenging of stigma and prejudice.

Specifically, the group agreed that individuals should have a right to:

access appropriate information and services, regardless of age, ethnicity, sexual orientation, place of residence, gender and disability, and be supported in doing so
express their sexual identity in a positive way
be respected for their personal views
be protected
expect responsible boundaries of confidentiality a

The last bullet point gives service providers a responsibility to be familiar with their employing organisation’s confidentiality guidelines.

The values and principles acknowledge that sexual activity can lead to positive health benefits and pleasure, and that it is important for an individual to feel confident to express their desires and boundaries. The strategy affirms diversity and aims to make sure that any resulting work is needs led, person centred and evidence based.

Setting the scene

While many people enjoy positive sexual health and relationships, there is little routinely collected data about positive sexual health. Such data is usually only obtained from specific studies. When trying to document the sexual health of the Scottish, or Lanarkshire, population, measures therefore often focus on “negative” outcomes, such as the number of sexually transmitted infections and bloodborne viruses diagnosed in a given period.

Infections that can be used to gauge changes in sexual behaviour are those causing acute symptoms, such as gonorrhoea in men. On the other hand, HIV and chlamydia are usually asymptomatic, and detecting them depends on the number of screening tests done, which in turn relies on the availability and accessibility of tests, the number of patients presenting for testing, and the range of factors that make clinicians suspect infection. Unintended pregnancy is also the result of behaviour that has put people at risk of infection.

Data collected routinely that relates to sexual health is usually obtained as a result of attendance at a health care clinic, a medical procedure or a hospital admission and includes data about sexually transmitted infections, teenage pregnancy and terminations.

Sexual health information is collated, analysed and published by Health Protection Scotland and the Information Services Division (ISD) , both of which are parts of NHS National Services Scotland.

Sexual health data for Scotland and Lanarkshire is analysed by NHS Lanarkshire as it becomes available and is published in the Facts and Figures section of the Lanarkshire sexual health web site

Except where stated otherwise, the data described below has been drawn from the ISD website.

Sexually transmitted infections

The majority of those presenting with a sexually transmitted infection (STI) are in the age range 15 to 30 years, with a median age of 24 in females and 26 in males. Almost a quarter of females attending are under 20 years of age. There are, however, a significant number of over 30s, who have come out of long-term relationships and meet new partners. They may not consider themselves at risk of infection, although they often have concerns about unwanted pregnancy.

Over the past 20 years, there have been significant changes in the pattern of infections diagnosed and treated at genitourinary medicine clinics. This is partly due to changes in the effectiveness of therapy that has helped to reduce the incidence of some bacterial infections, so allowing less easily treated viral infections to emerge. Health advisers play an important public health role in contacting partners of patients, so helping to reduce the pool of infections in the community. In addition, social marketing programmes have promoted attendance for asymptomatic screening.

Two important reports about sexually transmitted infections covering the period to December 2004 were published in 2005.

Mapping the issues was published by the UK Collaborative Group for HIV and STI Surveillance and considers data for both HIV and other Sexually Transmitted Infections across different areas of the United Kingdom. Findings include continued high levels of transmission of HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM), a steady increase in the number of HIV-infected black Africans in the UK, and limited evidence that heterosexual transmission of HIV within the UK is slowly increasing. The report also highlights continuing high transmission of other STIs, especially chlamydia among young people.