Sexual Health

The World Health Organisation (WHO) describes sexual health as,  

…“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. 

Maintaining good sexual health and wellbeing can have positive long-term effects on individuals, families, and wider society. Sexual health needs vary with age, gender, sexual orientation and ethnicity. Evidence shows some groups are disproportionately affected by poor sexual health than others. The consequences of this include: 

• Unplanned pregnancy and abortion, 
• Poor educational, social, and economic opportunities for teenage mothers, for young fathers, and their children, 
• Sexually transmitted infections (STIs), which can lead to long-term and life-threatening complications such as some cancers or chronic liver disease 
• HIV, or late diagnosis of HIV, can lead to avoidable illness, premature death, and increased transmission/infection rates, 
• Psychological harm, including from sexual coercion and abuse, 
• Stigma and discrimination, which can impact on access to services 
• Complications with conception, pregnancy and maternity outcomes for mother and baby. 

To experience positive sexual health, Lincolnshire residents need access to age-appropriate education, information, and support to help them make informed decisions, as well as access to high-quality services and treatments. Responsibility for commissioning sexual health, reproductive health and HIV services is shared across local authorities, clinical commissioning groups (CCGs) and NHS England.  

• The Health and Social Care Act 2012  divided commissioning responsibilities for sexual and reproductive health (SRH) and HIV services between local authorities, CCGs and NHS England. 
• Commissioning SRH services is supported by a suggested national service specification (OHID and UKHSA, 2023) and  a guide to whole system commissioning for sexual health, reproductive health and HIV (PHE, 2015) 
• The framework for sexual health improvement in England (2013) sets out the government’s ambitions for improving sexual health outcomes. 
• The HIV Action Plan (2021), sets out a commitment to achieving zero new HIV infections, AIDS and HIV-related deaths in England by 2030, and an 80% reduction in new HIV infections in England by 2025.  
• Chlamydia screening for 15–25-year-olds is offered through the National Chlamydia Screening Programme (NCSP).  
• SRH service delivery standards include: 
  • The British Association for Sexual Health and HIV (BASHH) guidelines  
  • The British HIV Association (BHIVA) clinical guidelines and the Standards of care for people living with HIV (2018). 
  • The Faculty of Sexual and Reproductive Healthcare (FSRH): Standards and Guidance. 
  • National Institute for Health and Care Excellence (NICE) guidelines [QS178] 
• Better Births Plan for Lincolnshire 2019-24 

As STIs are often asymptomatic, frequent STI screening of groups with greater sexual health needs is required as early detection and treatment can reduce long-term consequences, such as infertility and ectopic pregnancy. Controlling the spread of STIs relies on consistent and correct condom use; behaviour change to decrease overlapping or multiple partners; prompt access to testing and treatment; ensuring partners of positive cases are notified and tested; and in some cases, vaccination.  

Lincolnshire has consistently had lower rates of new STI diagnoses, compared with national rates (Source: OHID). Regarding chlamydia, national rates of detection are worsening and the trend in Lincolnshire reflects this (Source: OHID). However, the rate amongst those aged 15 to 24 is below the national average and below the levels recommended in order to decrease the prevalence of chlamydia in the general population. 

The latest (2020) national data sets cover the period when social distancing measures were in place. The data show a decrease in STI diagnoses reflecting a combination of reduced STI testing because of disruption to sexual health services, and changes in behaviour during the coronavirus pandemic. The highest rates of STI diagnoses continue to be recorded amongst young people 15 to 24 years; people of Black ethnicity; and gay, bisexual, and men who have sex with men (MSM). 

Lincolnshire has comparatively low rates of STI reinfection, or gonorrhoea, both of which are markers of unsafe sexual behaviour. 

Lincoln district area has the highest STI rates in Lincolnshire, for gonorrhoea, chlamydia, genital warts, and genital herpes. Lincoln’s STI diagnoses rate is the second highest in the East Midlands. In part, this may be because Lincoln has a higher proportion of young people (aged 16-24) than neighbouring populations. 

Lincolnshire is an area of low HIV prevalence, as defined by NICE. Late diagnosis is the most important predictor of HIV-related morbidity and short-term mortality. Lincolnshire’s percentage of HIV diagnoses made at a late stage of infection is higher than nationally – the 3rd highest in the East Midlands. Because there are low numbers of HIV diagnoses, data should be interpreted with caution (Source: UKHSA)  

In 2020, the UK and England met the UNAIDS 95-95-95 targets; 95% of people with HIV were diagnosed; 99% of the diagnosed were on treatment; and 97% of those on treatment were virally suppressed. In Lincolnshire, people (aged 15 years and over) diagnosed and on treatment was 99.3%, with 96.9% of those on treatment were virally supressed. 

13% of people living with HIV in Lincolnshire are of black African ethnicity but comprise only 0.2% of the population. National data shows black Africans to be the ethnic group with the highest rate of HIV. A third of new HIV diagnoses in Lincolnshire, in 2020, were of people who had been previously diagnosed with HIV abroad. 

An increased use of contraception can decrease the number of unintended pregnancies. Women who have unintended pregnancies are; more likely to present late for antenatal care, which can lead to obstetric complications; and are more likely to experience postnatal depression. Babies born in such circumstances are more likely to experience low birth weight, mental health issues, and poorer health outcomes. Babies born to women aged under 20, the age group at highest risk of unintended pregnancy, also exhibit higher rates of stillbirth, low birth weight, and considerably higher rates of infant mortality (Source: APPG Sexual & Reproductive Health). 

Proxy measures, such as abortion rates, teenage conceptions, and Long Acting Reversible Contraception (LARC) provision, are used to understand access to contraception. 

A national increase in abortion rate is not reflected in Lincolnshire – the county reporting the lowest total abortion rate in the East Midlands, and the fifth lowest rate in England. Lincolnshire has a comparatively high proportion of late-term abortions which indicates issues with timely access to abortion services. Lower percentages of conceptions leading to abortions for under 18s show significant variation within the county and this, too, may indicate barriers to abortion care for some residents. A comparatively high proportion of women under 25 in Lincolnshire, have had an abortion after a previous birth. This may indicate issues for women getting timely contraception after giving birth (Source: OHID) 

Lincolnshire’s under-18 conception rate is third highest in the East Midlands and the second highest rate of 16 ‘nearest neighbours’ (based on the Chartered Institute of Public Finance & Accountancy model). Lincolnshire shows variation in conception rates for under 18s;  South Kesteven having the lowest rate, and Lincoln the highest. Additionally, the most deprived population deciles have a higher rate of under-18 conceptions (Source: ONS) 

Lincolnshire’s total LARC prescription rate (excluding injections) has been consistently higher than England since 2014 (Source: OHID). However, access and availability of LARC is at risk due to a reduction in GP provision. 

Lincolnshire County Council (LCC) commission Lincolnshire Community Health Services (LCHS) to provide the Lincolnshire Integrated Sexual Health services (LiSH). LiSH provide open access, confidential, non-judgemental services including STI and blood-borne virus (BBV) testing, treatment, and management; the full range of contraceptive provision; health promotion; and prevention. 

The agreement allows LCHS to subcontract; Relate to provide psychosexual counselling; GPs to provide chlamydia screening; pharmacies to provide chlamydia screening and condom distribution; and, Prevent X, to provide online self-sampling services for chlamydia and gonorrhoea. 

A Section 75 agreement is in place with NHS England for LiSH to provide HIV treatment and care. 

LCC commissions GP practices to provide, fit, and remove, Long-Acting Reversible Contraception (LARC), such as implants and intrauterine devices (IUD/IUS). Community pharmacies are commissioned to provide a young people’s emergency contraception (EC) service for young people aged 13-19 and, for those with SEND, up to 25 years of age. 

LCC commission Positive Health to provide a sexual health outreach, HIV prevention and support service. 

A Sexual Assault Referral Centre in Lincoln supports adult victims, and Victim Support’s Castle Project supports children and young people (CYP) who have suffered child sexual exploitation, sexual violence, sexual offences, rape or sexual abuse. The Lincolnshire Paediatric Sexual Assault Referral Pathway outlines the process following a disclosure or incident of sexual abuse, assault or rape involving a child or young person.  

LCC Children’s Services provide support to teenage parents, and there is a specific pathway for a Child in Care, or a Care Leaver, becoming a parent. Early intervention, to engage the young mothers-to-be and fathers, can greatly improve the outcomes for parents and child. 

An ongoing  review of LCC commissioned SRH services will seek community and stakeholder views. Feedback will provide additional narrative ensuring all views are represented.  

• Needs of CYP with learning disabilities subjected to, or are at risk of, child exploitation are not fully understood.  
• Sexual assault and abuse of children under the age of 13 requires they receive robust local clinical support and sustained long term therapeutic support. 
• Reduction in GP provided LARC may result in unmet needs for contraception. Work is required to secure equitable access to LARC services. 
• Locally, abortion data reveal a barrier to accessing timely contraception, post-pregnancy. 
• Locally, abortion data also indicate problems with timely and equitable access to abortion services.  
• Comparatively higher under 18 conception rates warrant further analysis of local teenage pregnancy rates and risk factors. 
• National evidence suggests sex without a condom is increasingly common and there is low take-up of condom distribution schemes amongst some population groups. Here is an opportunity for a refreshed approach to condom distribution. 
• Chlamydia testing and detection rates are low in Lincolnshire. Without investigation and action, current testing and detection rates may not decrease prevalence of chlamydia. 
• Gay, bisexual, and other MSM, bear a disproportionate burden of ill health in three notable categories; sexual health and HIV; mental health; the use of alcohol, drugs and tobacco (Source: Public Health England, 2014). These issues must be addressed in unison because they co-exist and influence each other. 
• There are an increasing number of people overall, and an increasing number of older people living for long periods with HIV, with co-morbidities, and the health and care needs associated with ageing (Kings Fund, 2017). 
• There is a need to ensure young people receive high quality, comprehensive, relationship and sex education (RSE), and, “All schools must have in place a written policy for Relationships Education and RSE” (DoE). Recent national findings show only a third of pupils rate their RSE as Good, and a shortage of teachers who are trained, knowledgeable or confident in RSE. 

• Recommissioning of sexual health services, launching April 2024. 
• The three commissioning bodies for local SRH services should work collaboratively to map patient pathways and plan services.  
• A new national SRH strategy is expected, autumn 2022. Local commissioners and providers are to work through the new sexual health sector led improvement tool alongside the national strategy. 
• SRH should be embedded into new models of care, such as Integrated Care Systems (ICSs) and Primary Care Networks (PCNs).