 photo: Robert Daly©/Getty |
UK sexual health services are failing young people, says Dr Karen Rogstad, GUM Consultant at the Royal Hallamshire Hospital, Sheffield
The House of Commons Health Select Committee report on GUM and HIV services, highlights the current state of sexual healthcare provision in England, stating: “We have been appalled by the crisis in sexual health we have...witnessed in our enquiry.”
Young people are more at risk of sexually-transmitted infections (STIs) than older people. They are also more at risk of acquiring an STI if they are exposed to it, and more at risk of some complications.
For instance, young women are ten times more likely to be diagnosed with chlamydia than women from any other age group, and young gay men aged 20-24 three times more likely than other gay men to get gonorrhoea.
So it is essential that young people have access to good quality sexual health services, contraceptive services, and advice on sexuality and related concerns. Without them, young people’s health, both in the present and in future years, will suffer from complications of STIs, that can include infertility and death. (Unwanted pregnancies, too - but this article discussess primarily STI services as this is the area of expertise of the author.)
Genitourinary Medicine (GUM) clinics are a network of free clinics initially established in 1917. The clinics have seen a doubling in the number of people of all ages attending in the past 10 years. In 2002 there were more than 1.5 million attendances in England, Wales and Northern Ireland and a large proportion of these were young people.
Diagnoses for chlamydia in young women (16-19) attending GUM clinics increased threefold between 1995 and 2002, and gonorrhoea nearly as much. In men, gonorrhoea rates in the 20-24 year group increased more than threefold.
The number of 16-24 year olds receiving a diagnosis of HIV is small overall, forming about 11 per cent of total diagnoses. But it is increasing, because diagnoses of HIV are increasing. In 2002 there were 557 new HIV infections diagnosed in this age group, with young women bearing the brunt again: 324 infections, denoting 15.5 per cent of all diagnoses in women.
The increase in young asylum seekers/economic migrants using GUM services has been poorly documented. They often have additional problems because of displacement and previous sexual abuse, or may be victims of sexual trafficking.
GUM clinics are often seen by clients as having more confidentiality than other services. They can refer themselves without going through their GP.
Some choose to give a false name, but young people can be reassured that the service sends any tests off to laboratories using patient numbers rather than names, and there is no correspondence with GPs unless the client requests it or the GP is sent a referral letter. The notes for anyone attending GUM are separate to any other medical records they have, whether in hospital or general practice.
Though the standard of testing for STIs in GPs surgeries is improving, clinics remain the ideal setting for those requiring more than simply testing for chlamydia. Treatment at GUM clinics is free, an important factor for those not otherwise eligible for free prescriptions, and most treatments are given in the department, without the need to go and wait in a pharmacy.
Waiting times are the main concern and are unacceptably long. All patients should be seen within 48 hours, but recent surveys have shown average waiting times for routine appointments to be 12 days for men and 10 days for women, with a range of one day to seven weeks!
While waiting for an appointment, patients may be in pain, complications such as pelvic inflammatory disease could develop, and there is a longer time in which any infection could be passed on to someone else.
In other cases, however, the patient may appear to get better, so do not attend their appointment. This is not a great problem if the patient has a rash due to thrush, but if the rash is due to, say, syphilis, the infection will still be there.
Young people who have plucked up their courage to contact or attend the GUM clinic may lose their nerve if they are sent away with an appointment slip for 2-6 weeks later.
A novel approach in Sheffield has been a ‘Mystery Shopper’ scheme, where teenagers were given some training and then sent to assess services ‘undercover’ in their locality (See the Undercover report recently published for more details). Services were aware they would be visited, but the young people did not disclose their identity when they did so. Valuable feedback was provided on staff friendliness and difficulties encountered when trying to access a service.
Confidentiality, confidentiality, confidentiality! This is the over-riding message teenagers give in surveys asking their opinion on what they want from a sexual health service. It usually comes higher in priority than opening times, location, or a combined STI/contraceptive service.
The second priority is usually a friendly service that is non-judgemental. There is no excuse for any sexual health service for young people not to provide these key ingredients of confidentiality and friendliness.
The standard of the buildings of many GUM clinics needs to be improved. Young people should be seen in a pleasant environment and the fact that 20 per cent of clinics are in portacabins is disgraceful and does nothing to reduce the stigmatisation of those accessing such clinics.
The quality of tests used in all sexual health services must be improved. New diagnostic tests for chlamydia are much more sensitive than older tests and can be performed on urine for men and women who do not want a smear test. However in the majority of settings where chlamydia testing is undertaken, these new testing methods are still not used.
Clinics need to change to fit in with the lifestyles of modern teenagers, and many are doing so. The number of times patients need to attend the clinic has been reduced by the greater use of home treatments, for example for genital warts, and by writing or telephoning with results. Some clinics are exploring the use of websites, email and text messaging for booking appointments and contacting patients.
National guidelines have been produced on how to manage young people at risk of STIs. It is essential that a service is of high quality wherever it is provided and refers to these.
The Sexual Health and HIV Strategy aims to broaden sexual health services so that they are not just delivered by overburdened GUM clinics. It says increased testing for chlamydia and HIV should be done by GPs (level 1 service), and that community based ‘level 2’ GUM services should be provided by specialist GP practices.
The main stumbling blocks to their implementation are the need for additional financial and staffing resources and education of doctors and nurses providing the service.
One Stop Shops combining provision of STI and contraceptive services for young people have been successful in some settings but there is no evidence that the services are better than separate provision, and they do not obviate the need for specialist STI and contraceptive services.
The introduction of a national screening programme for chlamydia has been proposed and there are an increasing number of pilot sites. An effective programme would provide a dramatic improvement in young people’s health, reducing PID and ectopic pregnancies and preserving the fertility of women.
However the programme must target the right age group. Suggestions that women attending for their first cervical smear should be tested, means that the 16-20 year age group, with the highest incidence of chlamydia, would not be tested.
Targeted chlamydia testing of those young people accessing GPs or contraceptive clinics would be of some benefit but would still miss many girls at risk. Additionally there are no plans to screen young men for chlamydia, a great health inequality issue which fails to address half the problem!
Care for teenagers with HIV is currently becoming an issue and requires urgent attention, as those infected as children are now surviving into adulthood.
Sexual Health services in the UK require increased support. The increase in funding provided by the Department of Health must find its way from Primary Care Trusts (PCTs) to the GUM departments it is intended for, and there is no guarantee that PCTs will pass the funding on.
Young people, particularly those under 16 years, should be ‘fast-tracked’ when they attend or request appointments. Services need to regularly ensure they are young-people-friendly and young people’s views must be sought. And young people themselves have a responsibility to provide feedback so services can be improved.
Clint Walters, who runs HIFY, the UK’s young people’s HIV support group, says:“What they call a youth clinic often just means a waiting room where they’ve put a Nintendo game in the corner! What we need is to make them more attractive to young people and encourage more youth peer involvement. There is a lack of standardisation in especially the counselling part of GUM services when a young person goes for an STI or HIV test. We need to look at the actual forms too. They should be asking more useful questions about attitudes, sexual history, behaviour, the reasons why that person is having a test. You go through the form with a health adviser. But they don’t seem to have the time to do these properly. In San Francisco, where I trained with HIV services there, the health adviser would spend some time coming up with a plan of advice and counsel and talk you through a series of detailed questions. Staff here will spend 15 minutes and that’s it because they’re so overstretched. Data on behaviour is useful. Surveillance of sexual health for young people in England is bad; all we have is the Durex survey for detailed information about young people’s sexual health. Young people are especially worried about confidentiality and the issue should be discussed properly with them when they do a test and fill out forms. It’s such a huge thing for a young person to go into a clinic. It’s important to get a young person interacting with their health service at this first visit. If they get a negative encounter with staff, they won’t go back, things remain untreated, and they could delay further testing for years. The other problem is that most young people’s sexual health clinic close at 6pm. Again in America, a lot of young people’s clinics are open later or at the weekend. HIFY has just got funding to set up a London based evening clinic funded by King’s Fund, which we’ll run once a week and are looking for various workers at present.” Jenny Ross, Campaign Organiser for SPW (Student Partnerships Worldwide) adds:“There also needs to be a change in the healthcare professional’s approach to sexual health. Girls tend to be asked if they are sexually active and then just asked if they are on the pill. Boys are often not asked at all. The stigma attached to attending sexual health clinics is also an issue that needs to be addressed. You visit the dentist to get your teeth checked, and the opticians to get your eyes checked; visiting GUM clinics should be seen as an extension of this.” |
