2017 marks the 100th anniversary of the Venereal Diseases (VD) Act of 1917, a significant piece of legislation in the UK, which introduced the guiding principles of free and confidential treatment for sexually transmitted infections (STIs) that are still followed today. This act led to the creation of the first purpose built “VD clinics” or GUM (genitourinary) clinics as they are now known. Not long after the Act was passed, noted armed forces VD physician, L.W. Harrison wrote in the preface to his book on their treatment, that venereal diseases “levy a toll on our national resources that cannot be ignored”1.
Almost a hundred years later, this statement seems particularly relevant with rising rates of STIs and worsening financial pressures on the NHS. In 2012, the Health and Social Care Act gave Local Authorities the responsibility for commissioning sexual health services and many were put out for tender, leading to competition with private providers, such as Virgin Care. This along with £200 million cuts to Public Health in 2015 and a 40% reduction in local authority spending meant that in order to maintain the core services of STI testing and treatment, little resource has been left for other more holistic but just as vital aspects of sexual health, such as psychosexual care, safeguarding, sexual health promotion and education and outreach to vulnerable populations. Many family planning services have also been reduced with much contraception care pushed to already over-stretched GPs. Despite the government maintaining that NHS funding is being sustained and frontline care is not being affected, this is evidence that they are.
So what does this mean for people from Black, Asian and Minority Ethnic (BAME) backgrounds in the UK? Data collected by Public Health England show that BAME people are disproportionately affected by poor sexual health. Despite making up only 13% of the population, BAME people represent 45% of the people accessing HIV care in the UK and 80% of women accessing care2. Rates of new HIV diagnoses are rapidly increasing in BAME men who have sex with men3. Not only are rates of HIV higher, but BAME people are also more likely to be diagnosed at an advanced stage, which means they are more likely to suffer from ill health and ten times more likely to die from HIV-related diseases in the first year after diagnosis2. People self-identifying as Black have also been reported to have three times the rates of chlamydia and gonorrhoea and nine times the rate of trichomonas vaginalis than the general population4. BAME women are also more likely to have repeat abortions as 48% of Black women and 42% of women of mixed ethnicity who had an abortion in 2014 had had at least one previous abortion, compared with 37% of White women5.
Reasons for this higher burden of poor sexual health are complex and although it can partially be explained by the higher degree of socioeconomic deprivation faced by BAME people, this does not fully explain the difference, which is likely to be a consequence of complex social, cultural and behavioral factors6. One of the reasons frequently offered for this are the effect of colonialism and migration and this is most clearly seen with the global HIV epidemic. For example, a recent paper published on Media Diversified by Dr Lawrence Brown discussed how King Leopold and Belgian colonialism might have facilitated the spread of HIV-1 infection in the Congo7. It has also been postulated that the spread of HIV-2 from Guinea Bissau was likely to have been propagated by the war of independence and the colonial Portuguese army8. In the UK, it is likely that diaspora from parts of the world affected by colonialism face the consequences of this in complex ways leading to sexual health inequalities. They may also be deterred from seeking care due to cultural norms stigmatising discussing sex and seeking sexual health advice, concerns about being asked about their immigration status, insufficient knowledge of how to navigate the health system and language difficulties.
This reduction in sexual heath care funding is an important issue that needs to be discussed and shared more widely so that more people (especially those from BAME communities) become aware of the potential impact and are able to take action. This could include writing to local MPs, taking part in local Health and Wellbeing Boards through Healthwatch and participating in public consultations when local changes are proposed. There are also specialist organisations lobbying for awareness and change, such as the sexual health charity NAZ, which provides culturally specific services for BAME people and aims to advance research and policy in this area. An example of their work includes the MAN ON online platform (providing sexual health advice for BAME men who have sex with men) and lobbying the government for more detailed data on ethnicities (rather than wide categories such as Black Other, Asian) to better understand data trends, so that interventions can be targeted to specific populations in a culturally appropriate way. This is essential to ensure that interventions do not stigmatise the populations they are aimed at.
These cuts to sexual health services represent a false economy, as they will lead to rising STI rates with long-term complications such as infertility and sexual dysfunction, and more unwanted pregnancies. This impact will disproportionally affect BAME communities due to their greater burden of poor sexual health. One hundred years after the progressive VD Act was passed, it is vital that we fight for the future of free, confidential, holistic sexual health care and ensure that those most at need are able to access it.
- LW Harrison. The Diagnosis and Treatment of Venereal Diseases in General Practice (1918).
- HIV in the United Kingdom: 2016 report. Public Health England.
- Black and minority ethnic men who have sex with men: Project evaluation and systemic review (2016). Public Health England and De Montford University.
- Sexually Transmitted Infections in England, 2015. Public Health England.
- Abortion Statistics, England and Wales: 2014.
- Furegato M et al. Examining the role of socioeconomic deprivation in ethnic differences in sexually transmitted infection diagnosis rate in England: evidence from surveillance data. (2016) Epidemiology and Infection 144(15), pp. 3253-3262.
- Brown, L. The Ghost of King Leopold II Still Haunts Us: Belgium Colonization and the Ignition of the HIV Global Pandemic. Media Diversified 20 April 2015.
- Poulsen AG et al. Risk Factors for HIV-2 seropositivity among older people in Guinea Bissau. A search for the early history of HIV-2 infection. (2009) Scandinavian J of Infect Dis. 32(2), p169-175.
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Dr Rageshri Dhairyawan is an NHS consultant who has worked in sexual health and HIV medicine in London for over 8 years. She is also a member of the medical board at NAZ. She tweets regularly from @crageshri.