The cost of poor sexual health
The cost of poor sexual health |
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Key words: Sexual ill-heath, human cost, economic cost, sexually transmitted infections, unwanted pregnancies.
Introduction
Syphilis rates have increased by 500 percent in six years and gonorrhoea rates have doubled amongst teenage girls between 1996 and 2002. More than one in 10 prescriptions for the morning-after pill are for girls under the age of 16 years and some experts believe that one in 10 sexually active teenage girls may be infected with Chlamydia (1). With such an epidemic of sexually transmitted infections (STIs) having occurred in such a small period of time, if we are to develop a system of infection control then we need to be aware of the conditions which have given rise to such an explosion.
Societal Changes
In the pre-modern era, up to the eighteenth century, the predominant authority was the Church. The religious institutions which dominated this era were followed without question. The period from the eighteenth century up to the 1970s is known as the modern era. During this period of time there was a touching faith that science and technology would solve all the World’s problems. The predominant authority ceased to become the Church and was replaced by more tangible institutions such as the Government, public services, etc. From the 1970s to the current day is a period of time referred to as the post-modern era. The main characteristic of the post-modern era was that all of the big ideas – faith, philosophies, institutions – of the previous two periods have collapsed. Post-modernism claims that every view is relative and there is no such thing as absolute truth. Something might be ‘true’ for you, but not for me. Any attempt to persuade somebody of your own opinion or to claim that something is objectively true is seen as playing power games. The post-modern person feels free to ‘pick’n’mix’ their own customized lifestyle from all the beliefs and styles of history (2).
Baby Boomers and Baby Busters
Between the Second World War and the 1960s is a period of time during the modern era which has become known as the time of the baby boomers. Having lost so many young men of marrying age women suddenly found the need to compete strongly for a mate to provide for them (women having few employment opportunities). Fuelled by the dreams of comfort and unprecedented prosperity, the birth rate to couples in the West soared during this period. However, from the 1960s to the 1980s, the numbers tailed off drastically, or went ‘bust’, due in part to the explosion in contraception and abortion. The Buster mentality encouraged people to be pushy, driven, go-getting and achieve. By the end of the Buster period women were almost expected to have a career or at least to be in work, and were expected to contribute to the household finances. Whether as a consequence of this or not, the divorce rate rose significantly and the number of children living in broken relationships soared. Today’s generation of young adults has become known as Generation X; a term popularized by the Canadian writer Douglas Coupland in his 1992 novel of the same name. Generation X is a new emerging culture which is fundamentally different from those which went before it. Whereas Boomers put faith in science and technology to solve their problems, Xers have seen how science has polluted the earth. Whereas busters valued achievement, Xers looking at such values shrug their shoulders and ask the question ‘What’s the point?’ Xers are deeply suspicious of authority and are likely to consider it as oppressive and a power game. They are more likely to value relationships above success, community above fixed goals, and personal authenticity above success. However, although they value relationships they have been brought up as children in a period of time that lacks a role model for long term commitment within a relationship (3).
Xers and STIs
A generation which values relationships but has, for many, direct or indirect experience of broken parental relationships is likely to retreat from long-term commitment in their own relationships. Xers are a cautious generation in which to trust too much, or love too much is a doorway to pain. To them it would appear to be far safer to engage in short term
relationships. Such a generation longing to form close relationships but terrified if being hurt is a perfect era for the unprecedented spread of STIs.
Attitudes to sexually transmitted infections
People in the pre-modern era had a dim view of those infected with an STI. Leviticus 15:2-18 sets out clear guidance for the man with a urethral discharge who is considered ritually unclean as is anything or anyone that comes into contact with him. The advice is very precise and unambiguous e.g. Leviticus 15v.12 says ‘Any clay pot that the man touches must be broken, and any wooden bowl that he touches must be washed.’ Similarly, the Church viewed such a person as being subject to a ‘Punishment for the lewdness of mankind’. In 1321 Edward II founded the first of several British Lock Hospitals at Southwark, London dedicated to the treatment of patients with venereal diseases (4). If you were unlucky enough to have been a prostitute in Aberdeen in 1497 you were at risk of being branded on the cheek with a hot iron.
By the modern era there was a more compassionate view to those afflicted with an STI and specifically those engaged in prostitution. The Contagious Diseases Prevention Act (1864-86) charged the Admiralty and War Offices with regulating the spread of prostitution. If any woman known or identified to be a prostitute did not consent to an examination she could be forcibly detained in a certified hospital (5). The Social Hygiene Movement of the 1890s spread from North America and was an attempt to control the spread of STIs through education and was not limited to curbing prostitution. Control of venereal diseases was attempted through a combination of medical, legal, and educational reforms. In 1913, the British Government appointed the Royal Commission on Venereal Diseases to investigate the prevalence of infection in the UK and their effects on the community. The commission recommended that the registration and examination of prostitutes was ineffective in controlling the spread of infection (6). The main recommendation was the establishment of state treatment facilities throughout the country for all patients regardless of their ability to pay. Between 1919 and 1929 the voluntary agency the National Council for Combating Venereal Disease received finance from the British Government for educational programs and conferences.
Post World War 2
Prior to the Second World War there was only the most basic of treatments available for the two most notable STIs (gonorrhoea and syphilis). This coupled with fear of acquisition, and stigma should they be acquired, afforded some control over their spread. With the advent of penicillin and the realisation that there was now an effective treatment for these venereal diseases, there were some who were of the opinion that to use this antibiotic for these conditions would favour their spread. They were right. Having an effective treatment reduced the fear of acquisition which only led stigma as a controlling factor. Right up to the mid 1980s it was still not sociably acceptable to be afflicted with an STI, and such infections were little spoken about. With the emergence of HIV in the 1980s, and the availability of testing in 1985, there were strong moves to destigmatise STIs and GUM clinics in an effort to make it easier and more acceptable for those suspecting that they had been infected with HIV to come forward for testing. The success of these campaigns in the late 1980s and early 1990s removed the last control for the spread of STIs. Today we have treatable STIs for which there is no fear of acquisition along with their being no stigma in attending a GUM clinic.
Consequences of poor sexual health
The consequences of poor sexual health goes beyond the numerical increase in the number of persons infected with STIs that now attend GUM clinics. Only recently, increases in the number of cases of gonorrhoea led to the emergence of strains resistant to the most commonly used antibiotic – ciprofloxacin. Some GUM clinics have already moved to using the cephalosporin group of antibiotics as ciprofloxacin resistant strains have exceeded 5 percent of isolates. The prevalence of Chlamydia infection amongst young adults continues to cause alarm. What the eventual long term consequences will be from silent pelvic inflammatory disease and resultant infertility, ectopic pregnancy, and chronic pelvic pain may not be known for several decades. As asymptomatic chlamydia cervicitis rates increase we are likely to see an increase in the number of cases of neonatal ophthalmia. A worrying feature is that as more and more emphasis is being placed on first babies being discharged from hospital within 24 hours then there will be a delay in diagnosis and greater likelihood of respiratory infection. Similarly, as women infected with genital herpes increases so may neonatal herpetic infection. Vulval intraepithelial neoplasia and carcinoma linked to human papillomavirus type 16 may become more common amongst a younger age range of women as the numbers infected with genital warts increases. A sinister side to the continuing trivialisation of sexual intercourse in the media is the increased incidence of forced sexual assault or date rape. Too often the victim refuses to report the incident or talk to anyone about the episode.
Where do we go from here?
Living in Generation X makes it exceedingly difficult to employ measures to control the spread of STIs. The very word ‘control’ conjures up negative images of a power play to Xers. Attempts to make sex illegal under a certain age didn’t work in the past so there is no reason to suspect that it will work now. Telling people not to have sex will similarly be seen to be denying people pleasure. Any attempt to change a society by control or advice is extremely difficult. Denying treatment of STIs (as was considered in 1945 with the advent of penicillin), frightening people about the long term consequences of having an STI, or stigmatising STIs may have been effective at various times in the past. However, Generation X is aware of the past and is likely to adapt beyond these punitive measures should they ever be employed.
The only realistic answer to the increase in STIs currently being seen in the UK is to be reactive. Just as the Royal Commission on Venereal Disease recommended we need to provide state treatment facilities throughout the country for all patients regardless of their ability to pay and where people can be seen within 48 hours.
References
1. Health Protection Agency Statistics 2003.
2. M. Mahedy and J. Bernadi. A generation alone. IVP, USA 1994.
3. M. Starkey. God, sex and generation X. Triangle, UK 1997.
4. E. J. Burfurd. The orrible synne. A look at London lechery from Roman to Cromwellian times. London. Calder and Boyars. 1973.
5. V. Bullough and B. Bullough. The history of prostitution. New York University Books. 1964.
6. Royal Commission on Venereal Diseases. Final report of the commission. London, Eyre and Spottiswoode. 1916.
©2004 Sexual Health Matters. Published Quarterly by Express
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