Catherine Aicken

Who reports absence of sexual attraction in Britain? Evidence from national probability surveys

There is little evidence about the prevalence of absence of sexual attraction, or the characteristics of people reporting this, often labelled asexuals. We examine this using data from two probability surveys of the British general population, conducted in 1990–1991 and 2000–2001. Interviewers administered face-to-face and self-completion questionnaires to people aged 16–44 years (N = 13,765 in 1990–1991; N = 12,110 in 2000–2001). The proportion that had never experienced sexual attraction was 0.4% (95% CI: 0.3–0.5%) in 2000–2001, with no significant variation by gender or age, versus 0.9% (95% CI: 0.7–1.1%) in 1990–1991; p < 0.0001. Among these 79 respondents in 2000–2001, 28 (40.3% men; 33.9% women) had had sex, 19 (33.5% men; 20.9% women) had child(ren), and 17 (30.1% men; 19.2% women) were married. Three-quarters of asexual men and two-thirds of asexual women considered their frequency of sex ‘about right’, while 24.7% and 19.4%, respectively, ‘always enjoyed having sex’. As well as providing evidence on the distribution of asexuality in Britain, our data suggest that it cannot be assumed that those reporting no sexual attraction are sexually inexperienced or without intimate relationships. We recognise the possibility of social desirability bias given our reliance on self-reported data, but suggest that its effect is not easily predicted regarding absence of sexual attraction.

The eSexual Health Clinic system for management, prevention, and control of sexually transmitted infections: exploratory studies in people testing for Chlamydia trachomatis

BACKGROUND Self-directed and internet-based care are key elements of eHealth agendas. We developed a complex online clinical and public health intervention, the eSexual Health Clinic (eSHC), in which patients with genital chlamydia are diagnosed and medically managed via an automated online clinical consultation, leading to antibiotic collection from a pharmacy. Partner notification, health promotion, and capture of surveillance data are integral aspects of the eSHC. We aimed to assess the safety and feasibility of the eSHC as an alternative to routine care in non-randomised, exploratory proof-of-concept studies. METHODS Participants were untreated patients with chlamydia from genitourinary medicine clinics, untreated patients with chlamydia from six areas in England in the National Chlamydia Screening Programmes (NCSP) online postal testing service, or patients without chlamydia tested in the same six NCSP areas. All participants were aged 16 years or older. The primary outcome was the proportion of patients with chlamydia who consented to the online chlamydia pathway who then received appropriate clinical management either exclusively through online treatment or via a combination of online management and face-to-face care. We captured adverse treatment outcomes. FINDINGS Between July 21, 2014, and March 13, 2015, 2340 people used the eSHC. Of 197 eligible patients from genitourinary medicine clinics, 161 accessed results online. Of the 116 who consented to be included in the study, 112 (97%, 95% CI 91-99) received treatment, and 74 of those were treated exclusively online. Of the 146 eligible NCSP patients, 134 accessed their results online, and 105 consented to be included. 93 (89%, 95% CI 81-94) received treatment, and 60 were treated exclusively online. In both groups, median time to collection of treatment was within 1 day of receiving their diagnosis. 1776 (89%) of 1936 NCSP patients without chlamydia accessed results online. No adverse events were recorded. INTERPRETATION The eSHC is safe and feasible for management of patients with chlamydia, with preliminary evidence of similar treatment outcomes to those in traditional services. This innovative model could help to address growing clinical and public health needs. A definitive trial is needed to assess the efficacy, cost-effectiveness, and public health impact of this intervention. FUNDING UK Clinical Research Collaboration.

Building the bypass—implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009

Objective The objective of this study was to examine changes in patient routes into genitourinary medicine (GUM) clinics since policy changes in England sought to improve access to sexual healthcare. Methods Cross-sectional patient surveys at contrasting GUM clinics in England in 2004/2005 (seven clinics, 4600 patients) and 2009 (four clinics, 1504 patients). Patients completed a short pen-and-paper questionnaire that was then linked to an extract of their clinical data. Results Symptoms remained the most common reason patients cited for attending GUM (46% in both surveys), yet the proportion of patients having sexually transmitted infection (STI) diagnosis/es declined between 2004/2005 and 2009: 38%–29% of men and 28%–17% of women. Patients in 2009 waited less time before seeking care: median 7 days (2004/2005) versus 3 days (2009), in line with shorter GUM waiting times (median 7 vs 0 days, respectively). Fewer GUM patients in 2009 first sought care elsewhere (23% vs 39% in 2004/2005), largely from general practice, extending their time to attending GUM by a median of 2 days in 2009 (vs 5 days in 2004/2005). Patients with symptoms in 2009 were less likely than patients in 2004/2005 to report sex since recognising a need to seek care, but this was still reported by 25% of men and 38% of women (vs 44% and 58%, respectively, in 2004/2005). Conclusions Patient routes to GUM shortened between 2004/2005 and 2009. While GUM patients in 2009 were less likely overall to have STIs diagnosed, perhaps reflecting lower risk behaviour, there remains a substantial proportion of high-risk individuals requiring comprehensive care. Behavioural surveillance across all STI services is therefore essential to monitor and maximise their public health impact.

Interventions for increasing uptake of copper intrauterine devices: systematic review and meta-analysis.

BACKGROUND Copper intrauterine devices (copper-IUDs) are relatively safer, more effective and inexpensive compared with hormonal methods and are the most widely used reversible contraception in the world, but are underused in developed countries. We systematically reviewed randomized controlled trials and controlled before-and-after studies to determine the effectiveness of interventions for improving uptake of copper-IUDs. STUDY DESIGN We searched electronic databases for eligible trials. RevMan 5.1 was used to calculate Peto odd ratios with 95% confidence interval for dichotomous outcomes. RESULTS Nine studies representing 7960 women met our inclusion criteria, including seven randomized controlled trials and two controlled before-and-after studies. Meta-analysis from three studies showed contraceptive provision by community workers doubled uptake of IUD, and studies on antenatal contraceptive counselling showed similar increases. One study reported major increases in IUD uptake with postnatal couple contraceptive counselling; a study on postnatal home visits and two studies on postabortion contraceptive counselling did not reach statistical significance. CONCLUSIONS Community-based interventions and antenatal contraceptive counselling improved uptake of copper-IUD in studies mainly conducted in developing counties. Further research is needed on postabortion contraceptive counselling as well as longer-term effectiveness of interventions to improve use of copper-IUD.

Meeting sexual partners online: associated sexual behaviour and prevalent chlamydia infection among adolescents in Norway: a cross-sectional study

Objectives Evidence is mixed as to whether meeting sexual partners online (‘internet-partners’) is associated with risky sexual behaviour and/or sexually transmitted infection transmission. Accordingly, we sought to estimate the prevalence of reporting various online romantic and sexual activities among Norwegian adolescents, including internet-partners, and the reason for meeting them and to examine differences in sexual behaviour, partnership characteristics and chlamydia infection prevalence among those reporting internet-partners versus those reporting only offline partners. Methods Population-based cross-sectional survey among sexually experienced girls and boys, 15–20 years, using electronic questionnaires and collecting urine samples for Chlamydia trachomatis PCR testing (79% provided both, n=1023). We used logistic regression to examine associations, adjusting for potentially confounding variables. Results Overall, 30% of both genders reported internet-partners (ever). Boys (but not girls) with internet-partners had higher chlamydia prevalence than those reporting meeting sexual partners only offline (8.1%, 95% CI 4.3% to 13.7% vs 1.6%, 0.5% to 3.7%). Two-thirds of girls and 37% of boys reported meeting their most recent internet-partner to start a romantic relationship, while the remainder did so with the specific intention of having sex. Among both genders, reporting sexual (vs romantic) reasons for meeting their most recent internet-partners was associated with reporting several risky sexual behaviours, including multiple recent sex partners (adjusted OR girls: 3.27, boys: 2.48) and three-fold higher chlamydia prevalence. Conclusions This population-based study suggests that internet-partners are common among adolescents in Norway, and the reason for meeting them was more strongly associated with additionally reporting sexual risk behaviours and prevalent chlamydia infection than the internet itself as a meeting venue.

Use of the Internet for Sexual Health Among Sexually Experienced Persons Aged 16 to 44 Years: Evidence from a Nationally Representative Survey of the British Population.

Background Those who go online regarding their sexual health are potential users of new Internet-based sexual health interventions. Understanding the size and characteristics of this population is important in informing intervention design and delivery. Objective We aimed to estimate the prevalence in Britain of recent use of the Internet for key sexual health reasons (for chlamydia testing, human immunodeficiency virus [HIV] testing, sexually transmitted infection [STI] treatment, condoms/contraceptives, and help/advice with one’s sex life) and to identify associated sociodemographic and behavioral factors. Methods Complex survey analysis of data from 8926 sexually experienced persons aged 16-44 years in a 2010-2012 probability survey of Britain’s resident population. Prevalence of recent (past year) use of Internet sources for key sexual health reasons was estimated. Factors associated with use of information/support websites were identified using logistic regression to calculate age-adjusted odds ratios (AORs). Results Recent Internet use for chlamydia/HIV testing or STI treatment (combined) was very low (men: 0.31%; women: 0.16%), whereas 2.35% of men and 0.51% of women reported obtaining condoms/contraceptives online. Additionally, 4.49% of men and 4.57% of women reported recent use of information/support websites for advice/help with their sex lives. Prevalence declined with age (men 16-24 years: 7.7%; 35-44 years: 1.84%, P<.001; women 16-24 years: 7.8%; 35-44 years: 1.84%, P<.001). Use of information/support websites was strongly associated with men’s higher socioeconomic status (managerial/professional vs semiroutine/routine: AOR 1.93, 95% CI 1.27-2.93, P<.001). Despite no overall association with area-level deprivation, those in densely populated urban areas were more likely to report use of information/support websites than those living in rural areas (men: AOR 3.38, 95% CI 1.68-6.77, P<.001; women: AOR 2.51, 95% CI 1.34-4.70, P<.001). No statistically significant association was observed with number of sex partners reported after age adjustment, but use was more common among men reporting same-sex partners (last 5 years: AOR 2.44, 95% CI 1.27-4.70), women reporting sex with multiple partners without condoms (last year: AOR 1.90, 95% CI 1.11-3.26), and, among both sexes, reporting seeking sex online (last year, men: AOR 1.80, 95% CI 1.16-2.79; women: AOR 3.00, 95% CI 1.76-5.13). No association was observed with reporting STI diagnosis/es (last 5 years) or (after age adjustment) recent use of any STI service or non-Internet sexual health seeking. Conclusions A minority in Britain used the Internet for the sexual health reasons examined. Use of information/support websites was reported by those at greater STI risk, including younger people, indicating that demand for online STI services, and Internet-based sexual health interventions in general, may increase over time in this and subsequent cohorts. However, the impact on health inequalities needs addressing during design and evaluation of online sexual health interventions so that they maximize public health benefit.

Finding sexual partners online: prevalence and associations with sexual behaviour, STI diagnoses and other sexual health outcomes in the British population

Objectives Online venues might facilitate sexual encounters, but the extent to which finding partners online is associated with sexual risk behaviour and sexual health outcomes is unclear. We describe use of the internet to find sexual partners in a representative sample in Britain. Methods The third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) was a cross-sectional probability survey of 15 162 adults (aged 16–74 years) undertaken 2010–2012. We estimated prevalence of, and identified factors associated with, finding sexual partners online among those reporting ≥1 new sexual partners in the past year. Results Finding sexual partners online in the past year was reported by 17.6% (95% CI 15.6 to 19.9) of men and 10.1% (8.5–11.9) of women, and most common among those aged 35–44 years. After age-adjustment, those reporting a non-heterosexual identity were more likely to report this. Finding partners online was also associated with reporting sexual risk behaviours: condomless sex with ≥2 partners (adjusted OR (aOR) men: 1.52 (1.03 to 2.23); women: 1.62 (1.06 to 2.49)), concurrent partnerships (aOR men: 2.33 (1.62 to 3.35); women: 2.41 (1.49 to 3.87)) and higher partner numbers (reporting ≥5 partners aOR men: 5.95 (3.78 to 9.36); women: 7.00 (3.77 to 13.00)) (all past year). STI diagnoses and HIV testing were more common among men reporting finding partners online (adjusted for age, partner numbers, same-sex partnerships), but not women. Conclusions Finding partners online was associated with markers of sexual risk, which might be important for clinical risk assessment, but this was not matched by uptake of sexual health services. Online opportunities to find partners have increased, so these data might underestimate the importance of this social phenomenon for public health and STI control.

Making the Most of Obesity Research: Developing Research and Policy Objectives through Evidence Triangulation.

Drawing lessons from research can help policy makers make better decisions. If a large and methodologically varied body of research exists, as with childhood obesity, this is challenging. We present new research and policy objectives for child obesity developed by triangulating user involvement data with a mapping study of interventions aimed at reducing child obesity. The results suggest that enhancing mental wellbeing should be a policy objective, and greater involvement of peers and parents in the delivery of obesity interventions would be beneficial. We conclude that exploiting the evidence base through triangulation is a useful and valid method.

The Maximising STI Control (MSTIC) webtool: a new approach to facilitate the planning of services for sexually transmitted infections to maximise public health benefit

Abstract Background In the UK, national guidelines have sought to improve access to sexual health care, in part by expanding community-based provision of sexually transmitted infection (STI) testing, diagnosis, and care. Although useful data sources exist, there is little evidence for or guidance on the effect of different combinations of sexual health services on STI control locally. With finite resources, service planners need to identify the most effective combinations of STI services for their population. We sought to develop an evidence-based webtool aimed at supporting local service planning by synthesising the key data to show the relative consequences of different service configurations for different types of population. Methods We used a decision analytic model (DAM) to identify and model the effects of the characteristics of STI service provision, demography, and sexual behaviour that are likely to have the greatest effect on the incidence of common STIs. The DAM synthesised data from a range of sources, including census, surveillance systems, and probability sample surveys. We validated the DAM using data obtained from a standardised survey of people attending health services in four geographically and sociodemographically contrasting populations across England. The results of the model were presented as a webtool, requiring users to enter routinely available demographic data for their population along with characteristics and outcomes data for existing, proposed, or both health services providing care for STIs locally. The results are processed to estimate the effect on incidence of chlamydia and gonorrhoea locally. We consulted intended users attending a national sexual health conference to gain feedback on our webtool by giving them the opportunity to try the instrument for themselves, as well as ask questions of the designer and the mathematical modeller, for example, regarding the assumptions underlying the webtool. Findings The DAM identified the following demographic and service-level characteristics as key for estimating likely STI incidence in a locality: population type (urban, suburban, or semi-rural, taking account of assumptions about the areas ethnic mix and the proportion of men who have sex with men); size of the population aged 16–44 years, stratified by sex; type or types and capacity of services offering STI testing; level of partner notification achieved by these services; and mean delay between STI test and result. Consultation and usability testing revealed that commissioners and service planners were keen to explore the relative effect on disease control of varying assumptions about the type or types and capacity of services. However, clinicians were concerned about its reductionism and absence of individual patient perspective, although interested in the potential for exploring population outcomes for their services using an interactive decision-making instrument. We addressed these concerns by revising the accompanying user guide to ensure that we clearly explained the assumptions and limitations of our webtool, as well as including a technical appendix that provided details of the mathematical model. Interpretation Our evidence-based webtool allows service planning stakeholders to exploit routine data to inform rational STI service planning for their local population, showing how a one-size-fits-all approach does not apply to STI service planning. However, a willingness of users to engage with new approaches to service planning cannot be assumed. To achieve the buy-in necessary for the deployment of such instruments, user involvement has proven vital, resulting in improved communication and clarification of its assumptions and limitations. Evidence-based service planning needs to be promoted to ensure that STI services benefit both individual and public health. Funding MRC/DH Sexual Health and HIV Research Strategy Committee (grant G0601685).

Barriers and opportunities for evidence-based health service planning: the example of developing a Decision Analytic Model to plan services for sexually transmitted infections in the UK

BackgroundDecision Analytic Models (DAMs) are established means of evidence-synthesis to differentiate between health interventions. They have mainly been used to inform clinical decisions and health technology assessment at the national level, yet could also inform local health service planning. For this, a DAM must take into account the needs of the local population, but also the needs of those planning its services.Drawing on our experiences from stakeholder consultations, where we presented the potential utility of a DAM for planning local health services for sexually transmitted infections (STIs) in the UK, and the evidence it could use to inform decisions regarding different combinations of service provision, in terms of their costs, cost-effectiveness, and public health outcomes, we discuss the barriers perceived by stakeholders to the use of DAMs to inform service planning for local populations, including (1) a tension between individual and population perspectives; (2) reductionism; and (3) a lack of transparency regarding models, their assumptions, and the motivations of those generating models.DiscussionTechnological advances, including improvements in computing capability, are facilitating the development and use of models such as DAMs for health service planning. However, given the current scepticism among many stakeholders, encouraging informed critique and promoting trust in models to aid health service planning is vital, for example by making available and explicit the methods and assumptions underlying each model, associated limitations, and the process of validation. This can be achieved by consultation and training with the intended users, and by allowing access to the workings of the models, and their underlying assumptions (e.g. via the internet), to show how they actually work.SummaryConstructive discussion and education will help build a consensus on the purposes of STI services, the need for service planning to be evidence-based, and the potential for mathematical tools like DAMs to facilitate this.