Black people in UK have long been affected by poor sexual health. What are we doing to address it?
Sexually transmitted infections (STIs) are on the rise, and Black people continue to be disproportionately affected by poor sexual health. While some research has sought to explore why and how to address it, little has been done using a whole-systems, culturally appropriate approach to create meaningful and long-lasting change.
National surveillance data from PHE shows that STIs in England rose by 5% last year, up to 468,342 diagnoses. The most affected populations include people of Black ethnicity, men who have sex with men and young people.
Although people of white ethnicity made up the majority (64%) of all new STI diagnoses in 2019, the rate of STI diagnoses was highest in Black groups when considered as a proportion of their own ethnic group population size.
Source: Public Health England 2020 STI Annual data tables. Table 2: New STI diagnoses and rates by gender, sexual risk, age group and ethnic group, 2015-2020.
Source: Public Health England STI slide set 2019
Sexual health research projects
Recent research has looked at why Black people are disproportionately affected by poor sexual health, and has provided useful insights in terms of access, risk behaviours and attitudes:
An observational study by Aicken et al. (2019) found that differences in STI diagnosis outcomes between Black Caribbean (BC) and White British/Irish (WBI) men and women were not explained by the few ethnic differences which they identified in sexual healthcare-seeking and use.
In another study of sexual health clinic attendees, Coyle et al (2018) found that a history of STIs was reported more frequently by men and women of black/mixed Caribbean ethnicity, compared with white men and women. However, there were no significant differences in reported sexual behaviours, including condomless sex and multiple partners. This led the authors to conclude that sexual history and outcomes are likely to be influenced by factors beyond the individual, including partner behaviour and sexual networks.
Partner concurrency is considered a risk factor for STIs. In a recent qualitative study, Wayal et al (2020) explored the extent of and attitudes towards concurrency among BC in England. The researchers found that condomless sex was common with ex/long-term/married/cohabiting partners; whereas condoms were typically used with non-main partners. However, condom use declined with partnership duration and familiarity with partners. In contrast, awareness of partners' concurrency facilitated condom use, STI-testing, and partner notification. The authors concluded that concurrency type, its duration, and awareness influence sexual health choices, and recommended that data collection and partner notification mechanisms that incorporate these insights are required, in gender- and age-specific, culturally sensitive interventions.
When Aicken et al (2020) examined the impact different types of partnerships have on risk level and associated STI outcomes. They found that BC men’s partnerships were more often 'uncommitted regular' (35.4% vs 20.7%) and less often casual (38.5% vs 53.1%) than WBI men's partnerships. BC women's partnerships were more likely than WBI women's partnerships to involve age-mixing. In terms of outcomes, acute STI was higher among BC women than WBI women (OR: 2.29), with no difference among men. The authors concluded that differences in sexual partnerships and mixing do not explain elevated risk of acute STI diagnosis among heterosexual BC women sexual health clinic attendees. They recommended that better understanding of sexual networks is needed, and that factors beyond individual level need to be addressed to reduce population-level STI transmission.
Interpreting the research
This research is valuable and provides useful insights to inform service design and delivery. However, it still leaves many important questions unanswered:
If ethnic variations in partnership types nor sexual healthcare-seeking practices do not explain elevated poor sexual health, what does?
Do individuals and communities believe they may be at risk?
Does the recent surge in use of geo-spatial dating apps impact sexual behaviours and subsequently sexual health? If so, how can this be addressed?
Are individuals and communities aware of and can access the different tools to protect themselves? What are the enablers to take up preventative steps?
What is working for individuals who may be in the same sexual networks but have not got an STI due to adhering to protective practices?
Are there missed opportunities to contact individuals earlier before accessing sexual health clinics?
Do individuals have different options/preferences of how to access sexual health services? For example, innovative ‘click and collect’ self-sampling?
For One Voice Network, here is the biggest question of all: what is being done across the sector to address sexual health outcome disparities or provide answers to these important questions?
Campaigns & Education
In recent times, there has been a national sexual health campaign for young people and a national syphilis campaign for gay, bisexual and other men who have sex with men. However, there has been no national sexual health campaign targeted at enabling Black communities to take control of, and improve, their sexual health. If people are unaware that they may be disproportionately affected, how will they know the facts or be motivated to protect themselves?
Before closure in 2019, the Family Planning Association (FPA) was nationally commissioned to provide generic sexual health resources, however, since closing there has been little access to any sexual health information resources. Their sexual health information website Sexwise is still maintained, although it does not provide tailored BAME sexual health information and is geared towards young people.
HIV Prevention England also produce two generic pocket-size information booklets on syphilis and gonorrhoea. However, all these resources are generic.
We are unaware of any nationally available resources which have been developed by and with Black communities as the primary audience, communicating messages that are culturally relevant and which communities can embrace.
Local areas may have different initiatives to encourage Black communities to get tested and utilize protection, including enhanced provision/access. However, the lack of a national programme means that:
geographical disparities may persist as different areas take different approaches to addressing ethnic sexual health disparities.
the time, effort and resource used in different areas may be very costly and not as efficient.
As local funding for public health and health promotion shrinks, getting to a historically 'hard to reach' group may become deprioritized.
On the other hand, creating a long-term national programme which is coproduced with Black communities enables cost-effective investment in activities to address the issue, builds up widespread community trust to accept the benefits of taking up public health advice, and provides a mechanism to embed lessons learnt from past pilot projects.
Since 2016, Public Health England has run a series of annual innovation pilot programmes, and many projects have addressed BAME HIV and sexual health issues. While this is welcome, more is required to provide medium and long-term strategic solutions.
The lack of programmes, campaigns and resources can be proxy measures that show the level of priority which this issue has among decision-makers.
If we want to turn the tide on decades-old health inequalities, we need to roll out a strategic, systems-wide action plan that is based on evidence and tailored to community needs. Adequate funding is required over the long-term to change long-standing inequalities which may have been compounded by COVID-19 and an increasingly digital sexual health landscape.
Poor sexual health is one of the most stigmatized areas of public health, especially at the individual and community level.
Talking about sex may be taboo, but we need to facilitate honest conversations about STIs and safer sex in our communities. We need to raise awareness and enable effective risk management and prevention uptake, early diagnosis and treatment. Finally, we need to identify and tackle all the factors which have a direct link to poor sexual health outcomes in Black communities.
Aicken CRH, Wayal S, Blomquist PB, et al. Pathways to, and use of, sexual healthcare among Black Caribbean sexual health clinic attendees in England: evidence from cross-sectional bio-behavioural surveys. BMC Health Serv Res. 2019;19(1):668. Published 2019 Sep 18. doi:10.1186/s12913-019-4396-3
Aicken CR, Wayal S, Blomquist P, et al. Ethnic variations in sexual partnerships and mixing, and their association with STI diagnosis: findings from a cross-sectional biobehavioural survey of attendees of sexual health clinics across England. Sex Transm Infect. 2020;96(4):283-292. doi:10.1136/sextrans-2018-053739
Coyle RM, Miltz AR, Lampe FC on behalf of the AURAH Study Group, et al. Ethnicity and sexual risk in heterosexual people attending sexual health clinics in England: a cross-sectional, self-administered questionnaire study. Sexually Transmitted Infections 2018;94:384-391.
Public Health England. Sexually transmitted infections (STIs): annual data tables. (2020). Accessed September 2020. Available at <https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables>.
Wayal S, Gerressu M, Weatherburn P, Gilbart V, Hughes G, Mercer CH. A qualitative study of attitudes towards, typologies, and drivers of concurrent partnerships among people of black Caribbean ethnicity in England and their implications for STI prevention. BMC Public Health. 2020;20(1):188. Published 2020 Feb 6. doi:10.1186/s12889-020-8168-0