Dr Chris Wilkinson - ‘Providing an STD (Sexually Transmitted Disease)  service for youth’

As with any service for young people, the a sexual health service should fulfil accepted  basic minimum standards with regard to timing, accessibility, confidentiality and the attitudes of staff. One definition of sexual health and it’s main component parts are on this slide and I will state here that I am of the belief that such services should be along an integrated line, that is with facilities for both men and women, and facilities to get contraceptive care as well as care STDs, all at the same consultation.  My reasons for this is that not only do the clients not recognise the divide between family planning and genital medicine, but it is also difficult in practical terms to manage one without the other. 

At present although there are many community based young people’s services, there are few true sexual health services for young people.  This is in part because young people’s clinics have developed out of community family planning clinics which are not equipped or serviced adequately to carry out full STD testing.  Even now, because of the limitations available in technology, and difficulties in transportation of specimens to laboratories, a full community based sexual health service, meeting the standards of genitory medicine is not easily achieved.  This is further compromised by the lack of doctors and nurses who are trained in across both specialities, who are able to work sessionally.

I have been involved with two integrating sexual health clinics for young people.  The Open Doors in Hackney, and the Brook Clinic at St Thomas’ Hospital in London.  The former is community based and is fully integrated sexual health service for young men and women, and the latter is a similar set up, but is actually based in a hospital GUM clinic.  These like others could be regarded as prototypes or models of service provision.  Both of the reasons I have outlined, as well as for cost, it is difficult to set up such clinics nationally that are accessible to all.

I would like to concentrate really on why we need STD services accessible to all young people and what we can do to develop existing services by outlining the epidemiology of common STDs, by looking at why STDs are important, and just to look at whether we are looking at STDs as a nation well, and finally to consider what we can do in the future.

Data from the KC60 returns, which were collected from all GU clinics and is Department of Health data demonstrates the number of STD cases in England.  As virtually all cases of gonorrhoea pass through GU clinics, this is actually a reasonable estimate of the amount of the disease in the country as a whole.  And whilst this trend in the 80s was increasingly downward, there has been in the last two years, an increase of about 5% per annum.  Data on Chlamydia, was only started in 1989 when testing became the norm, have shown a rise in the last two years of  7% per annum.  But in fact for a number of reasons the number of cases of Chlamydia  are probably a gross under-estimate of the true number within the country as a whole.  and this is for two reasons,. firstly the test which we have available to us for routine testing does not detect all cases, and secondly a large number of family planning clinics and general practitioners are also testing and treating Chlamydia.  Just to put other STDs in perspective, wart infection, herpes are relatively common but when we consider HIV and syphilis for all intent and purposes these two infections are rare, especially in teenagers.  This gives us some idea of the number of cases and trends, but does not actually tell us about the prevalence or proportions of the population infected, and as Chlamydia is one of the most important STDs in the UK, I shall refer to this predominately from now on.  

So just how common is Chlamydia?  That is just how many of our friends, and how many of us in this hall actually have it at this very moment.  A number of studies have looked at Chlamydia rates in varying clinic populations.  Genitary medicine clinics, the STD clinics obviously seem to have the higher proportion, but even in family planning clinics, gynaecology outpatient clinics, termination of pregnancy clinics and antenatal clinics some studies have shown quite high percentages, and indeed a number of studies also looking at young people specifically have shown very high prevalence, and in the first 6 months of the St Thomas’ Brook Clinic the rate of positive Chlamydia infection was 25%.  And as a proportion of all those attending was 13%, which is still a high percent.  There was also geographical variations in the prevalence of STDs and I think it is reasonable to say, that inner cities  the rates of Chlamydia and gonorrhoea  are both higher with approx. 10 to 15 percent of all the countries of all the cases of gonorrhoea going through two of the large clinics in South London, whereas some of the other 200 GU clinics across the country, many of which are outside cities, hardly ever see a case at all.

So who gets STDs? In 1995 - 60% of these cases, were under 25.  90% were under 35.  The other interesting thing is that if you look at the difference between male and female, in younger age groups, far more women are being tested and found to be positive, than the male in the equivalent age group. Young women are more likely to have an infection diagnosed that young men.  This may be as a result of behavioural differences, but also physiological differences such as in differences in the reproductive tract in young women making them more liable to infection with Chlamydia than either young men or older women. 

Just turning to HIV, the number of young people being diagnosed as being HIV positive is small but one thing to note is that over half of all cases in this age group were people who were symptomatic or actually had Aids, and they are very likely to have caught their infections when they were in this age group.    So the safer sex message has undoubtedly played a part here, but the slow spread of HIV is also in part to being confined predominately to certain groups in the population.

As the majority of people infected with Chlamydia are without symptoms, it has important adverse consequences if untreated.  A way of identifying those who might be infected, and therefore need to be tested, needs to be sought.  A number of studies have addressed the risk factor for Chlamydia infection.  There is in fact no one discriminator, but young age, short duration of sexual partner, poor condom use, and being of black ethnic origin, seem to be the best indicators.  There is agreement between studies that these factors will screen out the majority of people with Chlamydia, but the specificity is poor and many people without infection would also be identified.  But if you just take the first three risk groups here, that actually includes the majority of sexually active young people.  So, that begs the question of are they all at risk and should they all be tested?

So we know that STDs are common, and we know that they affect the young and especially women, but are they important?

The reason that STDs are important is because they cause morbidity.  And that is the damage that such an infection does both in the short term, associated with the initial infection, and also in the long term as a result of ongoing chronic infection such as can occur such as in the case of HIV, or untreated syphilis.  These effects can be physical or psychological.  And at this point I would just like to say that we, as health care professionals can also cause serious morbidity if we are not precise in our diagnosis.  If we are going to diagnose an STD in an individual we have to be sure about that diagnosis, because the personal consequences for that person and their partner can be enormous. 

But obviously it is the nature of STDs that infection is not always limited to the individual, and some STDs are very infectious between sexual partners, and many of them can even infect the foetus resulting in foetal death, and congenital abnormality (such as in the case of syphilis), or infection of the new born, such as can occur with Chlamydia, gonorrhoea, syphilis, HIV and herpes.   In short they are a major public health problem.

To exemplify morbidity, I have chosen two examples.  These are Chlamydial infection and wart virus infection, both of which are common in young people.  Whilst the list of complications is not comprehensive, they are the most important, and it is of note that they mainly infect women.

Pelvic inflammatory disease, or PID, is a common diagnosis, and about 60% is caused by Chlamydia and about 20% of untreated cases of Chlamydia will go on to develop into PID.  The main long term complications are sub-fatality which occurs in about 9% of cases, atopic pregnancy - which although to die from atopic pregnancy is now rare, it is still a major cause of maternal mortality and morbidity.  And chronic pelvic pain which will reduce the quality of life considerably and may require major surgery as part of its management. 

Moving on to wart virus, although the wart viruses, or human papilloma viruses do not actually cause cervical cancer, of the 70 of the viruses types identified, three are closely implicated with its aetiology.  They can be transmitted sexually, and cervical cancer is related to first intercourse at a young age and a high number of sexual partners.  Just having said that, almost all women who have had warts will not ever go on to have pre-cancer, or overt cancer.

So STDs do not only lead to considerable cost to the individual, but also to the country.  And it is estimated that the treatment of PID and its consequences comes to around £50m per year.  I am not actually aware of the costs of the cervical screening programme of the costs of treating cervical cancer, but I suspect that it is a large figure.

We have really dealt with these first three points here, but the other point that is not commonly realised about many STDs is that they are without symptoms.  The implications of this is that many men and women, and especially the young, are entering into relationships ignorantly blind to the fact that they are either infected or can be infected.  And although many people realise that HIV has a non-symptomatic phase, they do not seem to apply that knowledge to other sexually transmitted diseases.  The lack of symptoms of others.  That means that we have either go out and look for cases, or we have to educate people to recognise when they are at risk.  We cannot expect an individual with no symptoms or information about his or her risk, to attend an STD clinic spontaneously.

It is also important to offer benefit from testing, and treatment of most STDs , curable ones such as Chlamydia and also chronic ones such as HIV, can offer benefits.  Notification of partner enables those who may have been in contact with an infection, but are a-symptomatic, to benefit from testing and treatment, preferably before any complications occur. 

Another important issue that is that STDs are potentially preventable.

So are we succeeding in the management of STDs?  I will just start with the information that in this country we have one of the most comprehensive and developed STD services in the world, and we are very lucky to have that.  But at the same time, we have rising instances of Chlamydia and gonorrhoea, the rate of re-infection of Chlamydia is probably is high - and is estimated to be around 19% in teenagers.  PID increased dramatically in the 70s and 80s and doesn’t appear to have declined.  Tubal factor sub-fertility  which is related to PID is common and etopic pregnancy rate is reported to be increasing. 

This is in sharp contrast to the situation in Sweden where in the early 1980s when faced with a 20% of young people attending clinics having Chlamydia, they targeted the rising unplanned pregnancy rates by aiming to change the attitudes and knowledge of young people by open rather than hiding issues, they introduced screening programmes, and they made partner notification or contact tracing a legal requirement.  Perhaps also very importantly they allocated resources to do this.    Chlamydia rates in Sweden is now down to 5% in the young people’s clinics and PID is also less common and they are expecting to see a change in the etopic pregnancy rate and sub-fertility rate.  But it is accepted that most of this probably resulted as a consequence of improved protection and treatment, rather than prevention through changes in behaviour.  They have also seen at the same time a drop in their un-planned pregnancy rate.

So, why are we not managing to deal with this major health problem optimally?  I think the main reasons are listed on this slide supplemented by the points raised previously.  And I think that nationally, and I am not pointing at any one part of the health service, we may not being actually achieving the quality of STD control available to us, especially in the case of young people.  And with the exception of some GU services, there is no standardised process of testing, that includes what test you use, how to test and when to test, and this leads to inconsistent management which varies, depending on where the client accesses health services. 

Often this is because inadequate funding - for instance those working in general practice would find it difficult to carry out contact tracing, whereas in the hospital set up we have got health advisors who are funded specifically to do this.  Just an example of the variation of care that can occur, is an audit that was carried out in my own hospital that found that women attending the emergency or gynaecology departments with PID were in general were inadequately investigated, they were treated with either inappropriate doses or types of antibiotics, and they received little or no advice with regard to partner notification and were therefore  put at risk of re-infection.  I am glad to say that we have now introduced a trust -wide protocol and training for all relevant staff, and the situation has been totally reversed and the standards are now high and more or less uniform irrelevant of which service a women accesses. 

And finally, dispute the acknowledged benefit from antibiotic prophylaxis prior to procedures such as abortion, which has an increased complication rate in the presence of STDs, many centres still fail to offer either prophylaxis, that is antibiotics, with the procedure or screening for STDs at same time as the procedure or just before.

So really what do I feel we can do to improve the sexual health of young people, even if they don’t actually recognise the term?  I think education about STDs to broaden their understanding.  We need to raise awareness to help young people recognise when they have been at risk, and may need to seek further advice with regard to STDs, and I think specific attention should be made to meet the needs of young men who are poorly catered for in these services.  On-going training and updating of healthcare workers is vital, and as primary care takes on a bigger role in the health provision of this country, practice nurses need have a central role here.  We should encourage new tests to be introduced for STDs, such as the chain reaction for the testing of Chlamydia that can be carried out on a urine sample and does not require a genital examination to be performed, which would be of great benefit to managing young people, although one has to bear in mind that there may be other reasons to examine a client.  Consideration should be made to the national standards for testing and also the cost benefits for the screening programme of Chlamydia for young people should receive public debate.

And finally, I would just like to say that someway ahead, or possibly around the corner, are a number of vaccines against STDs.  And there are trials undergoing for vaccines against HIV, herpes viruses, wart viruses and Chlamydia, and I await their introduction eagerly.

Muriel O’Driscoll  Psychosexual Counselling - Sexual Orientation.

I am a midwife and family planning nurse who is also a qualified psycho-sexual therapist and at present I am employed as the Senior Nurse at Wirral Brook advisory Centre for young people where their problems with relationships, health and sexuality are able to be discussed.

I have recently been working with young people, and in some cases their families, who have dilemmas and worries about their sexual orientation.  this is hardly ever a major problem for the individual concerned who, although being worried about his/her future and support from the family, has usually been convinced from a very early age of the ’difference’.  Their family or careers from Social Services, however have many problems of attitude, acceptance and ignorance and need education and support to enable them to accept and continue loving and caring and coming to terms with the loss of their expectations.

I feel that this topic is rarely given enough space for discussion.  It crosses every division in society of race, social class and geography and needs airing at conferences such as this.  I would be happy to present the topic, using care histories in order to stimulate discussion and awareness.

I do not intend to set myself up as an expert on any-thing, least of all on gay and lesbian issues.  My reason for wanting to bring this subject to the conference and give it an airing is mainly due to the fact that not enough is known or written about homosexual young people.  This is rather like the paucity of information available at the beginning of this century about all things sexual!

Homosexuality was redefined in 1974 as ‘Sexual Orientation Disturbance’ which implies that gay and lesbian youth are disturbed, or in conflict.  Being gay is not a psychiatric problem or disorder and as such cannot be ‘cured’, however well-meaning the efforts of doctors, psychiatrists and therapists.  Psycho-analysts still see it as an anal fixation problem.  One of the few booklets on this topic is produced by MIND, the leading mental health charity for England and Wales that seems to re-affirm that this ‘condition’ is wrong and can be cured.

I do not want to get into the medical or psychiatric discussion on the reasons for being gay but rather to focus on the dilemmas in a family for community when being gay can no longer be kept in a confused inner part of the individual concerned.

According to researchers from Kinsey in 1953 to Brechner in 1984 between 4% and 13% of the population as admitted some homosexual experience with greater numbers having some thoughts about their sexual preferences or come curiosity.  Looking at the lonely hearts columns in any local paper would give a biased view of the local community with many adverts for ‘BI-curious’ contacts as well as lesbian and gay requests for introductions.  Homosexual issues are quite rightly discussed openly in most media venues and the power of the media and popular culture should not be under-estimated.  Looking through recent issues of teen-age magazines like ‘Sugar’ and ‘Just 17’ can reveal letters and articles on this topic, so it must be something that young adults are concerned with.

In this climate many of our young people are confused about their sexuality and sexual curiosity and many feel that parents, teachers and other carers would not understand their confusion.

In Liverpool a few years ago a self help group was set up for young adults who saw themselves as gay or lesbian.  It was called ‘Phase’ n response to the adult view that their interest was ‘just a phase they were going through’.  Adult experts and agony aunts tend to minimise this sexual exploration and interest by re-calling their own experiences of a crush on the teachers or older pupils or out of reach pop stars or footballers.  this however is quite different as these icons are usually remote and completely unavailable and equates to the dream of owning/driving a Mercedes or playing the lead in a film!  Young people who are gay tell me that they do not have any more or less of these feelings for the unattainable than any one else.  What they do have is a very strong feeling that they are different from their friends and family from as far back as they can remember.

Perhaps I can illustrate this with a case study of a family who consulted me last year.

Darren was the middle child of Dave and Anne, with an older sister and a younger brother.  They were quite comfortable due to the hard work and ambition of Dave who now ran is own joinery company.  Darren was 16 when he was brought to see me with instructions for me to ‘cure’ him.  He was working part-time in the local McDonalds whilst studying at a local drama school where he was already making an impact in television small parts.  HE had recently come out to his family and they were distraught and demanded that he gave up is course immediately.  Darren could not leave home as he was financially dependent on his parents.

Darren had no problem with being gay, he had always felt different from his friends and brother, he had friends who were boys and girls and was a popular if somewhat solitary young man.  His main worries were not hurting his family, wanting to continue his education and being accepted as he was.  I had some sessions with his mother and other members of his family.  Like most mothers Anne was willing to stand by Darren and love him, but she was worried about all the negative publicity around gay issues.  In her mind Darren was already dying of AIDS and was more than likely being exploited by the Drama school.  She was grieving for her loss of her expected futures as she expected marriage, grandchildren and happiness for her son.

Dave could not bring himself to talk about the problem or to talk to Darren.  He wanted to remove Darren from the unsavoury influences and not let him out to go to drama school or any of the clubs where he may be influenced.  This was a natural reaction to protect his son but underlying this was his anti-gay upbringing and evident homophobia.

His siblings had great difficulty initially with the younger brother no longer wanting to share a bedroom with Darren or being seen in public with him, almost as though being gay was infectious!

His elder sister was initially shocked but then accepting as she had always been in tune with Darren and confronted him when younger when he exhibited his reluctance for aggression and rough and tumble games.

Grandma was expected to be shocked but was found in therapy that she was the turning point and the most influential person in the family.  Her acceptance and love for Darren was unconditional and proved to be pivotal in allowing Darren to express his feelings and future wishes.

Eventually this family came to terms with this perceived disaster in their lives and accepted the special gifts that Darren brought to the family and learnt together to look at themselves.

Just to prove that homosexuality crosses all races and cultures another client was Shumila, and eighteen year old student from a Hindu Indian family.  She had ‘come out’ at university and needed help in telling her family.  Shumila wore typical student uniform of Doc Martins and dungarees, with silver body piercing of nose and eye-brow.  Her head was shaved and her make-up quite startling.  As can be imagined there was a lot of reaction to Shumila’s announcement, but eventually there was understanding and compromise, as Shumila agreed to grow her hair again!

The main points that these cases brought to me were as follows:-

It can happen to us - Being gay can occur in any race, class, religion, culture, nationality, etc.  There is nothing that predisposes to being gay nor can anyone be influenced by another to be gay, although being or acting ‘camp’ may be an act used to entertain, to fit in or to avoid certain issues.

Individuals usually know from a very early age that they are different - even if they do not have the words to describe their feelings.  This may be exhibited in behaviours that are different from their peers or in feelings that may or may not be verbalised.

Families especially mothers feel a sense of loss for their preferred futures that usually include weddings and grandchildren and a sense of continuity.

Those who are closest may be the last to recognise the pain as excuses are made for behaviours such as ‘he’s always been sensitive/solitary/a show off/aggressive/ etc.  It comes as a shock when outsiders appear to know your son/daughter more intimately than you do.

Negative images in the media influence acceptance  Gay people are frequently portrayed as sad, disturbed, promiscuous, child molesters, over the top personalities, outside of acceptable society.  This is despite the efforts of soap operas and films and specialist programmes that of course are not usually watched by the straight population.

Absence of a family role model.  As children we learn most of our living and social skills from our family or carers.  For the gay young person there is a need to look further afield for role models.  Because of the widespread homophobia there may be a reluctance to air their fears, hopes and feelings with those closest to them and then it is much more difficult and shocking when the individual ‘comes out’.

So far this has all sounded depressing as far as families and individuals are concerned.  Although as I said before I am no expert, just a listener and supporter of young people, I have been looking at some areas where we as carers, parents and concerned adults may make some improvements.

More discussion about sexuality in general and homosexuality as part of this.  Homophobia and not wanting to be different is rife amongst the young and is influenced by what they hear from those adults closest to them.  We must take as much care to avoid homophobic language, jokes and references as we would with racist or sexist comments.

Unconditional love and support made evident by all who care for young people.  This is usually implied by parents and carers but needs spelling out and stating frequently.  Parents and carers still love and support their children who may be or become disabled, dependent, criminals and even drug addicts but have more of a problem with those who are gay or lesbian.  Even if they could accept, they may give the impression that they would not and so cut off the supportive lifeline to their children through fear of their reaction.

Education and awareness for carers, teachers, social workers and Doctors surrounding homosexuality in order for facts or myths to be discussed with young people.

Positive images of gay and lesbian people to be celebrated e.g. Chris Smith labour Member of Parliament made his homosexuality known before standing as an MP so removing the treat of exposure and sensation by the media, as well as being accepted as a person first and a gay MP second.

Bringing gay and lesbian issues into mainstream education and discussion  so that they are not always identified with the ‘abnormal’  or deviant areas of society.

Celebrating difference and accepting diversity  The world would be a very monochrome place if we were all the same.  People are not better of higher than others, just different and that diversity makes life great.

Finally the most important thing that we can give to any one is the gift of respect for self in order that respect can be given to others.

I would like to thank the organisers of this conference for giving me the opportunity to air this subject and I hope that you will all consider your own attitudes and actions in your work with young people.