The history of sexual health
The World Health Organisation (WHO) defines sexual health as ‘a state of physical, mental and social well-being in relation to sexuality’. It is an important area of public health and the current investment in England in sexual, reproductive and HIV services by local councils is around £534 million – the third largest area of public health spend. In England in 2021, over four million consultations at sexual health services (SHS) took place, nearly 16% more than the previous year.
Birth control
The modern birth control movement started in the late 19th century. A threat to the male dominated society, controlling fertility was believed to encourage infidelity and faced considerable opposition from the church, state and medical professionals. For example, when prominent atheists, Annie Besant and Charles Bradlaugh, re-published Charles Knowlton’s ‘Fruits of Philosophy’ – a leaflet which argued that it was “more moral to prevent conception of children, than, after they are born, to murder them by want of food, air and clothing”, they were charged and found guilty of breaching the Obscene Publications Act of 1857.[i]
As is still the case, health outcomes were hugely dependent on women’s circumstances and those who suffered the greatest were more likely to live in poverty and overcrowded squalor, suffer more from ill-health and infant-mortality, and had no access to birth control.
During the early 20th century, the consensus between doctors remained that birth control led to prostitution and immorality, and the topic was not taught to medical students. In London in 1921, Marie Stopes, a biologist and campaigner, opened the first sexual health clinic in Britain, the Mothers’ Clinic for Constructive Birth Control. The clinic was run by nurses rather than doctors and female doctors were used for referrals. It was the first time qualified clinical staff gave contraceptive advice and it marked the beginning of Sexual Health Services (SHS) being a medical speciality rather than a social or commercial activity. Four years later, in May 1925, the first centre outside of London, in Wolverhampton, was opened.
Clinic numbers began to increase and in 1930, the National Birth Control Council (NBCC) was formed from 20 clinics so ‘married people may space or limit their families and thus mitigate the evils of ill-health and poverty’.[ii] The NBCC coordinated the work of Maternity and Child Welfare Councils but, as had been true for decades, unmarried and working-class women were offered little support or opportunities to seek advice. By 1939, NBCC member societies merged into The Family Planning Association (FPA).
Following the NHS’ formation in 1948, local authorities took over maternity and child welfare centres, providing discretionary provision of contraceptive advice. The FPA continued to campaign for the NHS to provide family planning services and in 1952 FPA clinics began to offer pre-marital advice to women.
During the 1960s, huge progress was made. The first oral contraceptive was introduced in 1961 and in 1967 laws surrounding sexuality began to change, accurately reflecting public attitudes and the problems faced by people in everyday society. The Abortion Act legalised abortion, in certain circumstances, in the UK and was a key public health driver, reducing the incidence of maternal mortality and morbidity. The Family Planning Act 1967 enabled local authorities to give contraceptive advice and supplies under the NHS and included unmarried women, although it was at the discretion of the authority.
Teenage pregnancy
Between 1993 and 2020, the under-18 conception rate in England and Wales decreased by 69%, from 42 per 1,000 women to 13 per 1,000 women.[iii] Rising educational and employment aspirations, changing housing availability, improved access to contraception and developments in sexual and reproductive health education in schools have all been credited as drivers of this fall.[iv] [v] This dramatic reduction serves as evidence of the successes of public health interventions and exemplifies the positive impact of preventative action on health outcomes.
Whilst much progress has been made, the under-18 conception rate remains much higher than that of comparable European countries. Targeted interventions for young women living in high risk or deprived areas, universal access to reproductive and sexual health advice and increased funding across the four nations to deliver these services should remain a priority to continue the trend of declining conception rates and to bring the UK in line with equivalent European countries.[vi]
Sexually transmitted infections (STIs)
During the first world war about 5% of British troops were infected with a sexually transmitted infection (STI) and over 400,000 British or allied men were admitted to hospital as a result of one to over 5 times the hospitalisation rate for trench foot. By the middle of the war, 50% of infertility in women was caused by gonorrhoea and 30% of children in blind schools were there as a result of syphilis. In 1916, the Local Government Board issued the Public Health Venereal Diseases Regulations based on recommendations by the Royal Commission on Venereal Diseases. These regulations led to the development of a nationwide network of clinics based in hospitals in heavily populated areas offering free confidential diagnosis and treatment for syphilis, gonorrhoea and chancroid.
Attitudes began to change and there was a greater need to manage venereal disease as well as a greater recognition of its effects. It was thought that educating civil and military populations against the dangers of venereal disease and the importance of sexual hygiene would improve case rates[vii]
Today, SHS in the UK encompass a wide variety of services, including the provision of sexual health or GUM clinics. STI screening, for infections such as chlamydia, gonorrhoea, syphilis or HIV are all available, as well as genital examinations, cervical screenings and advice on pregnancy and contraceptives.
In the 1980’s a new STI was discovered – Human Immunodeficiency Virus (HIV), which can lead to the development of the disease Acquired Immunodeficiency Syndrome (AIDs). The HIV/AIDs crisis was a global public health emergency which for years highly stigmatised homosexual relationships and according to the WHO, has killed over 40.1 million people. The first diagnoses of an AIDS related illness in the UK was in 1981, and a report of the gentleman’s death was published by The Lancet. By 1985, 58 AIDS-related deaths had been recorded in Britain. As a response to growing infection rates and hospitalisations, a year later the UK Government launched the major public health information campaign “AIDS: don’t die of ignorance”. A leaflet about AIDS was delivered to every household in the UK alongside a television advert designed to get people to read the information leaflet. By 1996, a combination of antiretroviral drugs, known as triple combination threat therapy (HAART), became standard treatment for HIV infection. HAART maintains the patient’s immune system function and prevents opportunistic infection, which is often the cause of death. Crucially, it also prevents the transmission of HIV if the HIV-positive patient maintains an undetectable viral load. The use of HAART has saved millions of lives, reducing AIDs-related deaths by between 60% and 80%, and is noted to be on the greatest public health success stories globally.
Over time, the stigma surrounding STIs has lessened and in 2002, the National Chlamydia Screening Programme was established to ‘prevent and control chlamydia through early detection and treatment of asymptomatic infection; reduce onward transmission to sexual partners; and prevent the consequences of untreated infection’.
As a result of the 2012 Health and Social Care Act, sexual, reproductive health and HIV commissioning arrangements were split between NHS England and local authorities. The English HIV & Sexual Health Commissioners’ Group (EHSHCG) was set up in 2013, supported by ADPH and funded by Local Government Association (LGA), as a collaborative network to support commissioners and improve the delivery of local, integrated services through sector-led improvement. It is now hosted by ADPH and funded through LAPH subscriptions.
As well as improvements in screening and treatment, further developments in preventing STIs have continued to emerge. For example, PrEP, Pre-exposure prophylaxis, is a drug taken by those at risk of contracting HIV but are not yet infected, reducing the risk of contracting the virus after exposure by 99%. Improving PrEP take up is however heavily reliant on public health services and the EHSHCG have facilitated projects to increase access to PrEP, such as their PrEP Commissioning Champions, facilitating collaborative commissioning by working with NHSE and the DHSC.
In 2022, over two million sexual health screens for STIs took place at SHS, an increase of 13.4% compared to 2021. Both gonorrhoea and syphilis returned to the high levels of pre-pandemic reporting, and gonorrhoea diagnoses were the highest reported annually since records began.[viii] This is evidence of the continued need for well-funded, accessible SHS alongside public health messaging which successfully raises awareness of the importance of testing and treatment.
SHS in the UK have taken centuries to develop into the inclusive and vital public health provision that they are in the present day. Medical developments have allowed STIs to be controlled, and the introduction of HAART and PrEP curtailed a public health crisis that killed millions globally. However, effective SHS require much more than medical interventions alone, and the continued funding of and equitable access to education and support is vital for good sexual health practice.
[i] https://www.fsrh.org/documents/history-of-the-fsrh/
[ii] https://www.fpa.org.uk/about-fpa/
[iii] https://www.nuffieldtrust.org.uk/resource/teenage-pregnancy
[iv] http://www.cpc.ac.uk/docs/2020_PB60_Understanding_declining_teenage_pregnancy_rates_in_England.pdf
[v] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255510/#
[vi] https://stateofchildhealth.rcpch.ac.uk/evidence/health-behaviours/conceptions-in-young-people/#page-section-11
[vii] https://blog.nationalarchives.gov.uk/temptation-troops/
[viii] https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables/sexually-transmitted-infections-and-screening-for-chlamydia-in-england-2022-report