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A high price is paid by ignoring the needs of the promiscuous 10%
With few exceptions every month uncovers more evidence of the declining sexual health of the UK population.1,2 Levels of chlamydia have more than doubled in the past 10 years,1 nearly forgotten infections such as syphilis have returned to plague new generations3 and overall, sexually transmitted infections (STIs) are higher than at any time since the National Health Service began in 1948.4 Furthermore, while some reductions have been made in teenage pregnancy rates, these have been modest and still leave the UK with one of the highest rates in Europe.5 By and large our attempts to avoid a sexual health crisis and, more recently, to manage it have failed.
At the core of this crisis is an unwillingness to engage with the “promiscuous” 10%; a significant group of people who have multiple sexual partners, may have started sex early in life, and may even access paid sex and pornography. For instance, one in ten young people have had sex at 14 or younger.6 Such individuals who have sex at an earlier age are less likely to use condoms at sexual initiation, are more likely to become pregnant earlier,6 and accumulate more sexual partners per year.7 Changing their behaviour is central to improving sexual health but these individuals are rarely the principal consideration when developing interventions. For instance, school based sex education is the main source of information on sex issues for young people.6 Evidence suggests that early sex education does not encourage early sexual activity8 but is central to young people obtaining appropriate information on sex, sexual health and relationships along with the skills required to manage these.9 However, with the exception of some biological details, sex education effectively remains outside of the national curriculum for England. Decisions on when, what, and how much sex education (if any) is delivered are made largely within each school. Thus, at national levels the choice to guarantee the delivery of high quality sex education is evaded, often to avoid offence to a sensitive but vocal minority. Equally at a local level the same individuals steer teachers and governors away from the needs of the promiscuous 10% and paradoxically towards the wishes of those relatively unaffected by the sexual health crisis. The result can be little or irrelevant sex education, delivered by embarrassed teachers after many children have become sexually active.
The irony of sexual health interventions accommodating those least affected, rather than those most at risk, continues outside of schools. Among UK adults, around one in ten women have had at least two sexual partners concurrently in the past 12 months and for men this rises to nearly one in eight.10 Such behaviour is regularly the focus of television, film, and other forms of media content but in general without reference to sexual health. In the United States, (a source of broadcast content for many countries), 64% of general television programmes contain some form of sexual activity, yet just 15% deal with sexual health.11 Equally in the UK, adverts use strong sexual imagery to sell everything from alcohol to cars. However, the condom is practically never seen unwrapped by a well toned man or a half naked woman.12 Despite around half of the sexually active adult population using them,13 portrayals of condoms remain limited to the cold or the comedic. Overall, adverts and programmes seem unwilling to deal with sexual health issues. Those that try often suffer a backlash from the vocal minority who seem accepting of widespread sexual innuendo but critical of media addressing sexual health through the same mechanisms. Recently, for example, in the UK a billboard advertisement for Durex used inflated condoms to spell out the words Roger More and was banned after just a few complaints.14 However, advertising regulations15 should only prevent messages or images that may cause serious or widespread offence. Overall, UK advertising and programme content avoid condoms, negotiation of safe sex, and other aspects of sexual health. In doing so they may reduce complaints from the more sensitive but only at the expense of safer sex featuring as a facet of promiscuous behaviour.
The results of not engaging the promiscuous now include 10% of sexually active UK adults having had a sexually transmitted infection and around 13% of the general population having visited a genitourinary medicine (GUM) clinic.16 Among those with higher numbers of sexual partners the figures are even worse with over one in five individuals who have had 10 or more sexual partners having been to a GUM clinic.17
In fact, sexual health services, in particular GUM services, may be the first place promiscuous individuals receive information they regard as relevant. All too often this comes after they have been infected with a STI or found themselves unintentionally pregnant. However, GUM clinics in the UK remain grossly under-resourced to work with these individuals, to change their sexual practice, and to explore the infection status and sexual practice of their contacts.18 As a result the same individuals return for treatment with new infections often after acquiring new unprotected sexual contacts.19 Thus, over three quarters of GUM attendees in London have had a previous STI20 and almost a quarter of 12 to 15 year olds presenting at GUM clinics with gonorrhoea return to services with another episode of the disease within 12 months.18
It seems that even in specialist settings there is not enough time and resource to meet the needs of the 10% and denigrating opinion about their behaviour makes them unlikely to complain publicly. Consequently, increasing waiting lists at GUM services mean that in the UK nearly half of STIs are now first diagnosed in primary care.21 However, it is at least questionable how well general practitioners are prepared to tackle the needs of the promiscuous 10%, to discuss their sexual practice, and advise on protecting their own and their partners’ sexual health.22 For instance, nearly 5% of adult males in the UK have paid for sex10 and both prostitutes and clients are more likely to have high numbers of sexual partners and be at heightened risk of STIs.23,24 Discussion of such risk taking is unlikely as personal conflicts between generations, sexualities, and even religious beliefs inhibit communication not just in schools and the media but also between health professionals and the more promiscuous. As a result issues such as prostitution are addressed largely as judicial problems instead of as public health concerns.
The promiscuous 10% could access sexual health information on the internet. The medium is already strongly associated with sex and in just one month almost a quarter of all home internet users in the UK will access pornography, with a quarter of these being students.25 Furthermore, those using the medium to find sexual partners take more sexual risks26 and, in the case of young people, start sex earlier.27 Many good sexual health sites are already available. However for the young, protective filters on home computers sensibly bar access to pornography but incidentally often bar access to safer sex sites as well.28 Parents can change web browsers to allow access to safe sex sites but this requires a sexual health dialogue between parent and child. All too often this dialogue is absent especially for those who have started sex or even an interest in sex early.6
In reality of course there is no specific promiscuous 10% as many individuals move in and out of polygamy, serial monogamy, long term monogamy, and even abstinence. However, meeting the needs of the most sexually active, whatever the terminology, lies in giving more consideration to their needs when planning educational curriculums, media campaigns, and health interventions. With some areas seeing one in ten young people with a STI29 perhaps a greater level of statutory, pertinent, and timely sex education is now required despite the complaints of a few. More realistic portrayals of sex, condom use, and safer sex practice in the media may again upset a few but may also help counter the sexual innuendo that currently promotes promiscuity but provides no hint of safe sex behaviour. Perhaps even the occasional advert could suggest that condoms, not just aftershave or the right jeans, may help improve your sex life. The price for this will undoubtedly be complaints from a few individuals who find open discussion of sex and sexuality difficult to condone. However, with spiralling numbers of STIs and continuing unwanted pregnancies the price of ignoring the needs of the promiscuous 10% will be far greater.
A high price is paid by ignoring the needs of the promiscuous 10%
Conflicts of interest: none declared.