Critically Appraising the Sexual Health Strategy

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Critically Appraising the Sexual Health Strategy

• Dr Paul Flowers
• Reader in Psychology
• Glasgow Caledonian University

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Structure of presentation

• The strategy as a viable document
• Confusion surrounding the prioritisation of
  social versus individual issues
• Blurring and tension between socio-cultural and
  medical/public health perspectives
• The loss of focus upon clear target groups
• Absences within the strategy

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The strategy as a viable document too inclusive?

• It is well written and comprehensive
• This is its main strength and its main weakness
• It is incredibly inclusive and this means very
  little is emphasised and very little is
  prioritised

4
The strategy as a viable document the readers
role of interpretation

• The strategy demands a major and active role of
  interpretation it includes everything (in
  footnotes) and delivers nothing
• The role of interpretation is dangerous in terms
  of implementation (competing viewpoints all
  equally correct potentially problematic with
  cross disciplinary work)
• The sensitivity of some points seems to have led
  to them being deliberately introduced through the
  back door (in footnotes and references)

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The strategy as a viable document interpretation
and joint work

• Joint work relying on interpretation is
  problematic and will prevent implementation and
  action
• People will retain the status quo and not address
  the innovative attempt to influence the cultural
  and social factors which impact upon sexual well
  being

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Cultural, social vs individual issues the issue
of prioritisation

• The strategy presents an inclusive, all
  encompassing, focus upon all individuals and
  their sexual health and well-being
• Every individual can see their own sexual health
  and well being written into the strategy

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Cultural, social vs individual issues the issue
of prioritisation

• The strategy states that sexual ill health can
  affect anyone throughout their life and that it
  is important to recognise that sexual well-being
  is an issue for all of society.
• In the penultimate section (6.1), it states that
  even more importantly, individuals have a
  responsibility for managing their own sexual
  health and maximising their sexual well-being

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Cultural, social vs individual issues the issue
of prioritisation

• This levelling and sharing of sexual ill health
  across the population is both welcome and
  dangerous.
• Implicitly, it suggests there is equality in
  access to sexual well-being, that we all face the
  same barriers, opportunities and service
  requirements. This clearly is not true.

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Cultural, social vs individual issues the issue
of prioritisation

• The issue of targeting, prioritisation and
  emphasis is dealt with most directly in section
  4.
• Yet it fails to deliver any clear understanding
  of why the groups of people are listed.

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Cultural, social vs individual issues the issue
of prioritisation

• There are gaps within the evidence base regarding
  prioritisation
• However, the existing epidemiology clearly shows
  that if you are a man having sex with other men,
  or indeed someone who has travelled, or been born
  in, Sub-Saharan Africa, given the same sexual
  behaviour as most people in Scotland, you are
  significantly more likely to be involved in
  exposure to STIs and specifically HIV

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Cultural, social vs individual issues the issue
of prioritisation

• Prevalence of STIs (and HIV) and patterns of
  sexual mixing all dictate the likelihood of
  sexual behaviour impacting upon sexual health.
• People living with HIV, or indeed Hep B, are a
  clear priority group in terms of promoting
  positive sexual health as they are involved in
  every new infection.

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Cultural, social vs individual issues the issue
of prioritisation

• There are clear inequalities in sexual health,
  clear socially, culturally and medically defined
  groups of people who consistently face far more
  barriers to sexual well-being than the average
  person in Scotland.
• These inequalities must be addressed clearly in
  the shape of the prioritisation of certain groups
  (e.g. based on incidence, prevalence, health
  economics).

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Cultural, social vs individual issues the issue
of prioritisation

• The strategy reflects various social institutions
  such as the family (parents and carers), the
  school and the role of reproductive services.
• Given the acknowledgement of social and cultural
  factors it seems strange not to explicitly
  highlight the role of community.
• It seems as if an individualistic model of health
  is implicit here and that ideas of community,
  which often shape sexual mixing and sexual
  conduct, are not fully addressed and utilised in
  terms of promoting sexual well-being. (e.g. gay,
  BME, faith and geographic communities)

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The cultural and social vs public health
perspectives

• Given the importance of social and cultural
  influences upon sexual health, the strategy seems
  to shift emphasis towards a public health (and
  more medical) perspective from section 4.1.
  onwards
• In terms of the recommendations following 4.49,
  we see that HIV testing should be made in the
  context of the HIV test being presented as a
  routine recommended test.

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The cultural and social vs public health
perspectives

• Given the stigma, social and sexual exclusion
  experienced by many positive people following HIV
  diagnosis I am concerned about the routine
  description of the HIV antibody test (Flowers,
  Duncan and Frankis, 1998 Flowers et al 2003)
• Given the strategies emphasis upon the social and
  cultural I think this recommendation is giving
  out the wrong message a solely medical one
• Research shows that the HIV antibody test is
  never routine and that appropriate pre- and post-
  test counselling should always be offered
• Such discussions should be entrenched within the
  social and cultural issues surrounding HIV status
  (namely the legal context, community expectations
  of status disclosure, assumptions of status and
  negotiating sex). (Flowers et al., 1999)

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Absences in the strategy

• The central role of stigma, shame and guilt
  associated by many with acquiring STIs seems
  surprisingly absent from much of the strategy
  (could be included in page 15-17).
• In reducing stigma and promoting sexual health
  check ups many of the barriers to sexual
  well-being could be reduced (its mentioned on
  page 17). Decreased delay would reduce new
  infections.
•  
• Overall the strategy does not address the
  untapped expertise of people who have acquired,
  are privileged by, or indeed have learnt the
  skills required for sexual well-being. These
  people offer a great resource for everyone and an
  opportunity for skills transfer. Also taps in to
  lack of evidence on this subject.
•   

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Absences in the strategy

• National audit/library of resources (tier one),
  reducing inconsistencies, duplications
• National monitoring of agencies, in terms of
  remit, output, effectiveness (allowing
  interagency comparisons and highlighting examples
  of good practice)
• Under-representation of womens sexual
  dysfunction (e.g. inoragsmia, vaginismus).
  Sexual dysfunction seems very male oriented.
•  

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Absences in the strategy

• Targets and priorities should be set to ensure
  strategic direction and guide implementation
• Outcomes could be based upon the social and
  cultural model of sexual well-being (not simply
  medical or public health)
• E.g.
• Made an informed decision around HIV testing
• Lack of regret at first sexual encounter
• Celibacy as a positive choice
• Promotion of better masturbation techniques
• Reciprocal pleasure in sex with regular partner
•  

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Absences in the strategy the crisis in gay mens
HIV prevention

• The crisis in gay mens HIV prevention is not
  mentioned (rising UAI, rising resistant strains
  of HIV)
• Increases in UAI amongst gay men in Australia
  (Van de Ven, Rawstorne, Crawford and Kippax,
  2002) in USA (Ekstrand, Stall, Paul, Osmond and
  Coates, 1999), in UK (Dodds, Nardone, Mercey and
  Johnson's, 2000 Elford, Bolding and Sherr, 2002
  Rani, Woolley and Chandiok, 2000 Williamson and
  Hart, 2003)
• In Scotland, Williamson and Hart (2003) reported
  that UAI increased from 32 to 34 and 43 across
  the three years.
• The reported increase in figures for UAI with
  casual partners from 10.7 to 11.2 and sharper
  increase to 18.6 in 2002
•  

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Absences in the strategy the medicalisation of
HIV care

• The medicalisation of HIV care seems absent
  although there is a worrying suggestion that
  agencies for people living with HIV should expand
  to a broader remit of STIs.
• While the number of positive people in medical
  care grows, consultation times within clinics
  shrink and there is an increasingly narrow focus
  of care. Adherence, side-effects, Multi-drug
  resistant virus
• The needs of HIV positive people have increased
  and not decreased
•  

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Conclusion

• I think that the strategy is incredibly
  refreshing and positive in terms of its general
  ethos.
• It represents a welcome move away from a medical
  model of sexual health towards embracing the
  social and cultural determinants of sexual
  health.
• However, as it stands, it does not present a
  clear framework of priorities and strategic
  direction.
• It comprehensive coverage of many key areas puts
  them on the agenda but may lead to confusion and
  disarray in terms of the process of
  implementation.