Abstract
Young people, who are aged 15 to 24 years, in the United Kingdom witness significant changes throughout their lives as they sexually mature. During the transition to a university environment, young people may be exposed to new social factors (e.g. alcohol consumption, peer pressure) and psychological factors (e.g. depression), coinciding with demographic factors (e.g. ethnicity, gender, sexual orientation). For example, subjection to new social experiences such as alcohol intoxication during this transition may increase the risk of adverse sexual health outcomes.
Epidemiological data collected on sexual health suggests that young people are victims of adverse sexual health outcomes more frequently than other age groups. Therefore, in this review, the demographic and social factors that may explain this increased risk of negative sexual health outcomes in young people are critically evaluated and discussed, and are used to inform possible suggestions for the promotion of positive sexual health outcomes through Sex and Relationships Education (SRE) in secondary education.
Introduction
Since 2017, it has been reported that there was an overall increase of 5% in the diagnosis of sexually transmitted infections (STIs) in the general population of England (Public Health England, 2018). Public Health England (2018) identified young people, namely those aged between 15 and 24 years, as a group of England’s population who are at high risk of adverse sexual health outcomes. Overall, young adults report the highest diagnosis rate of STIs such as chlamydia, gonorrhoea and syphilis.
According to the current working definition (World Health Organisation, 2006), sexual health is:
“… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and
respectful approach to sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”[1]
Thus, it is important to recognise that adverse sexual health outcomes are not exclusive to STI transmission but may also include other consequences such as unwanted pregnancy. However – for the purpose of this article – adverse sexual outcomes will be defined as the transmission of STIs.
Following the emergence of three drug resistant Neisseria gonorrhoea in England in 2018, there has been a 26% increase in the diagnosis of gonorrhoea across England since 2017 (Public Health England, 2018). As evidence is emerging to suggest that STIs are beginning to develop resistance to contemporary pharmaceutical interventions, it is becoming imperative that the ability to predict people’s individual sexual health needs, risks and challenges as far in advance as possible is accomplished. This ability to accurately predict sexual risk behaviours and, therefore, adverse sexual health outcomes within England’s population would facilitate positive sexual health promotion amongst the general population of England.
Previous research has indicated that demographic factors (e.g. ethnicity; Public Health England, 2018), social factors (e.g. alcohol consumption; Martino et al., 2011), and genetic factors (e.g. DNA variations; Mallard et al., 2018) significantly influence likelihood of engagement in sexual risk behaviour. Therefore – within the proceeding review – the recognised influencers of sexual risk behaviour are explored and evaluated, in order to aid the production of a model that can be used to predict sexual risk behaviours and adverse sexual health outcomes. Throughout the article, there are a number of hypotheses that may be explored in future research, in order to combat adverse sexual health outcomes within the United Kingdom.
Demographic Influencers
Previous research suggests that demographic factors, which are factors used to define the characteristics of a population, can strongly influence likelihood of sexual health risk. Variables such as age, race and gender are particularly relevant to predicting sexual risk; however – since this article discusses predictors exclusive to young adults aged 15 to 24 years – age is not a variable that will be discussed.
Ethnicity
The Strategic Action Plan for Health Promotion and Reproductive Health and HIV identifies black and minority ethnic populations (BME) as a group at disproportionate risk to Human Immunodeficiency Virus (HIV) (Public Health England, 2015). Public Health England (2018) established that the highest population rates of STI diagnosis are among people of black ethnicity; however, the population rates varied significantly amongst BME populations. 
As presented in Table 1, populations of Black British ethnicity have the highest rate of chlamydia diagnoses in England, being approximately 295% higher than those of white ethnicity. It is also important to recognise from Table 1 that, regardless of ethnicity, population rates of chlamydia diagnoses peaked in 2018.
Those of Asian or Asian British ethnicity report the lowest population rate of chlamydia diagnoses of all ethnicities; however – similar to populations of other ethnicities, the population rate of chlamydia diagnosis for Asian or Asian British ethnic groups has increased each year between 2014 and 2018. It can therefore be concluded that ethnicity significantly influences sexual risk behaviour, as findings presented in Table 1 are indicative of population rates of chlamydia diagnoses differing significantly dependent upon ethnicity.
Hypothesis 1: There will be a difference between the self-report rates of STI diagnoses between ethnic groups.
Hypothesis 2: The total STI diagnosis by population rate will have increased within 2019, and will continue to increase in preceding years.
Gender
Extant research indicates that gender is not a significant predictor of sexual risk behaviour because it does not induce, inhibit nor moderate sexual behaviour (Patrick & Maggs, 2009). However, contrary to findings of Patrick & Maggs (2009), the Public Health England (2019) reports that there were approximately 12.5% more new STI diagnoses in men than in women. This would suggest that men are more likely to participate in risky sexual behaviour, such as sex without a condom, and thus have a heightened risk of adverse sexual health outcomes, for example STI transmission.
Albeit, research into the association between gender and sexual health is limited, and so, further research is necessary to fully comprehend associations between gender and engagement within sexual risk behaviour.
Hypotheses 3: People who sexually identify as ‘Male’ are more likely to engage within sexual risk behaviour than people who sexually identify as ‘Female’, thus increasing probability of adverse sexual health outcomes.
Religion
Religion is an important predictor of engagement in sexual risk behaviour and the likelihood of adverse sexual health consequences because it is generally viewed as providing an important moral framework that sanctions safe sex behaviour (Chanakira et al., 2014). England’s society is generally beginning to withdraw from traditional religious attitudes, such as the notion of abstaining from sexual intercourse before marriage, which likely explains the overall 5% increase in STI diagnoses reported across England (Public Health England, 2018).
Persons who report high religiosity are at a decreased likelihood of engaging in substance use, such as drinking alcohol (Rodriguez, Neighbours, and Foster, 2014). It is therefore likely that individuals who report high religiosity are also at decreased risk of engaging within sexual risk behaviour, and thus, are at decreased risk of experiencing adverse sexual health outcomes (see ‘Alcohol’).
Religion has also been observed to influence coping strategies that evolve to overcome negative emotion. High-risk groups, such as young people aged 15 to 24 years, are likely to feel that religion somewhat condemns their sexual desires, causing them to turn to maladaptive coping strategies to overcome such feelings (Jaspal, 2018). Maladaptive coping strategies can be seen in the form of denial or passing (see ‘Intrapsychic Coping Strategies’), and they are likely to reduce self-efficacy and increase depressive emotion, inducing increased probability of adverse sexual health outcomes (see ‘Depression’).
Hypothesis 4: Young people in the United Kingdom are increasingly likely to report lower levels of religiosity, compared to older generations within the United Kingdom. There will be a negative correlation between religiosity and likelihood to engage within sexual risk behaviour, and thus younger people in the United Kingdom are increasingly likely to experience adverse sexual health outcomes.
Sexual Identity
In the contemporary world, it is becoming increasingly common and acceptable for people to openly identify their sexuality as something that does not conform with the global heteronormative society. In recent years, research concerning sexual health has thrived as data specific to those who engage in same-sex sexual activity or otherwise do not identify as heterosexual has been collected.
Public Health England (2015) recognised that men who have sex with men (MSM) generally experience an increased burden of STIs and HIV, thus placing them as a high-risk group. This is indicative of MSM communities being more likely to engage and participate in sexual risk behaviour, explaining the increased population rate of STI transmission amongst MSM. This complements findings of research conducted in previous years, which found that MSM are – over time – engaging in more risky sexual behaviour (i.e. a 6% increase in the incidence of MSM having unprotected anal sex between 1991 and 2001) and are therefore more likely to experience negative sexual health outcomes such as STI transmission (Chen, et al.., 2002). Explanations for this increased occurrence of adverse sexual health consequences within MSM originate from factors such as substance abuse (see ‘Alcohol Intake’), and as such abuse has been identified as a potential contributor to risky sexual behaviour in the past (e.g. Vanable et al., 2004).
It is important to consider that, although previous research has indicated that there is an association between identity principles and engagement in sexual risk behaviour, research is restrictive as to the reasoning of why MSM populations are at heightened likelihood to engage within said behaviour.
One such explanation, however, is that a heteronormative society may encourage persons who identify as homosexual to associate themselves with homonegativity, thus reducing self-efficacy (Jaspal, 2018). Self-efficacy is a key motivator in sustained behaviour change, and coping strategies that one chooses to employ may influence their self-efficacy and subsequently affect sexual risk (see ‘Depression’; ‘Coping Strategies’)
The Identity Process Theory compliments this idea by suggesting that assimilation, accommodation and evaluation are the processes by which individuals are able to construct their identity (Jaspal, 2014). Intrapsychic coping strategies, such as denial, may result in psychological regression, and thus, reduce self-efficacy, subsequently increasing the risk of those in the MSM community and other at-risk populations – like young people – to development of mental health conditions such as depression.
In order to reduce sexual health risk amongst high risk populations, clinicians need to begin to encourage adaptive coping techniques, rather than maladaptive coping strategies. The coping mechanisms that one employs can clearly influence sexual behaviour, and so, it is necessary for practitioners to have full comprehension of how the two factors interrelate (Jaspal, 2018).
Hypothesis 5: Individuals who do not sexually identify as heterosexual are at increased sexual risk compared to individuals who do identify as heterosexual.
Hypothesis 6: Individuals who do not sexually identify as heterosexual are at increased risk of depressive symptoms compared to individuals who do identify as heterosexual. [See Hypothesis 9; Hypothesis 10]
Social Influences
Social factors, which affect a person’s personality, attitudes and lifestyles, have proven to be significant in determining sexual risk behaviour. Factors such as mental health and substance abuse have been associated with sexual risk specifically, and so can be utilised as predictors of sexual health risk and adverse sexual health outcomes.
Social influences are commonly those that directly govern risk behaviour, and are in themselves influenced by demographic factors. Although social influences are factors that one is exposed to in their environment, existing research supports the idea that genetic factors may also influence engagement in sexual risk behaviours such as alcohol consumption.
For example, GABRA-2 is a gene encoding the alpha-2 subunit of the GABRA-A receptor, which influences the aetiology of problematic drinking (Mallard, Ashenhurst, Harden, and Fromme, 2018). The haplotypes ‘TTGACTC’ and ‘TTGACTT’ have also been associated with a lower overall likelihood to use illicit drugs. Thus, it can be concluded that – in addition to demographic factors – genetic factors may predispose a person to increased engagement within sexual risk behaviours.
Alcohol Consumption
Young people aged 15 to 24 years, in particular undergraduate students, have been negatively portrayed by the media within England. Media portrayal of undergraduate students often includes presenting highly active social lives, including drinking and being sexually active (Patrick & Maggs, 2009). Tt is widely believed by professionals that this portrayal exerts intense social pressure on undergraduate students – and other young people within England – to conform to the student stereotype (Chanakira et al., 2014).
Martino et al. (2006) conducted studies that investigate the social factors that affect the drinking habits of adolescents and concluded that social observations and interactions – such as the media – form the ‘norms’ for drinking behaviour. Alcohol use is widely known to produce a range of social and behavioural implications (often inconsistent), including increasing the likelihood of engaging within sexual risk behaviour (e.g. Dermen et al., 1998; Testa & Collins, 1997). In previous research conducted upon undergraduate students, alcohol consumption is often seen as a ‘social lubricant’ at the centre of student’s social lives, and its uses in social contexts can often lead to risky sexual behaviour.
This increased risk of engagement in sexual risk behaviour can be explained via the Alcohol Myopia Theory (AMT), which suggests that alcohol intoxication impairs aspects of information processing, and so it regularly restricts the range of social cues that one is able to perceive and process accurately in a social situation (Patrick & Maggs, 2009). It is therefore likely that under the influence of alcohol, one is less able to make informed decisions upon their sexual behaviours (e.g. wearing a condom) because they are less able to accurately assess risk, increasing the likelihood of adverse sexual health outcomes such as pregnancy and STI transmission.
Although it is widely accepted that the effect of alcohol upon human social behaviours and emotions vary and is highly irregular, a bivariate association between alcohol intoxication and sexual risk behaviour has been identified at a global level (Brown et al., 2007). This global association stresses the importance of alcohol intoxication upon attitudes towards sexual behaviour, making it imperative that the association is further studied to allow clinicians to make accurate estimations of sexual risk.
A developed understanding of the psychoactive effects of alcohol upon one’s mind would subsequently reduce the frequency of adverse sexual health outcomes if utilised by healthcare
professionals appropriately. This, in turn, would reduce reliance upon pharmacological treatments for common STIs and allow preventative methods to be enforced for groups predicted to be at high risk.
Hypothesis 7: Persons who have high alcohol uptake are at greater risk of experiencing adverse sexual health outcomes.
Hypothesis 8: There is an association between alcohol uptake in young people aged 15 to 24 years, and media representation of young people.
Depression
Prior research has linked mental health disorders, namely depression, with high risk behaviours such as alcohol consumption and drug use (T. Taniguchi et al., 2013). Choi et al. (2017) suggested that bridge symptoms of depression, such as sleep, may interfere with sexual appraisals by distorting one’s ability to accurately estimate risk, thus increasing likelihood of persons engaging within risky sexual behaviour.
Increases in severity of depression have been found to be independently associated with a linear decline in CD4 cell count (T. Taniguchi et al., 2013). CD4 is a glycoprotein that plays a central role in immune protection by aiding the development of antibodies by Beta Cells, and inducing macrophage production (Zhu & Paul, 2008). CD4 cells are therefore vital in an immune response, as they help to fight infection and therefore indicate good physical health. However, with a reduced CD4 cell count and therefore being relatively immunosuppressed, individuals who are suffering from depression are at greater risk of HIV infection following sexual contact with a HIV infected-person, as the body’s natural immune response is less successful in protecting itself from invading pathogens (T. Taniguchi et al., 2013). It is therefore concluded that depression, and other mental health conditions alike, directly increase the probability of adverse sexual health outcomes by inhibiting the body’s natural immune response.
It is therefore necessary that, in addition to developing sexual health promotion strategies that are targeted towards those who are depressed, depression screening should be introduced so that pharmacotherapy techniques can be employed to increase CD4 cell count and therefore decrease sexual risk.
Depression is also likely to reduce self-efficacy, which may cause a person to turn to intrapsychic coping strategies such as denial and passing. In particular, denial is relevant to predicting sexual risk because it may be a case that persons refuse to believe that they are at a high risk of STI infection (Jaspal, 2018), and so do not regularly go for screening. On the contrary, somebody suffering from depression may turn to substance abuse as a method of coping with their thoughts and their feelings.
Similar to depression screening, screening for high risk sexual behaviours (e.g. sex without a condom, alcohol intoxication) should also therefore be employed to ensure that the sexual health promotion strategies can be appropriately employed to people. It may be a case that, in addition to promotion of sexual health, promotion of mental health is also required.
Hypothesis 9: Increased risk of adverse sexual health outcomes is observable within persons who suffer from psychological disorders, such as depression.
Hypothesis 10: Psychological disorders, such as depression, directly predispose a person to increased risk of adverse sexual health outcomes, because they increase the likelihood of engagement within sexual risk behaviour, and they decrease the likelihood of an effective immune response to protect against STIs.
Attitudes towards Sexual Health Screening
Attitudes towards sexual health screening, which traditionally involve visiting a sexual health clinic or community contraceptive clinic, are generally negative (Denison et al., 2017; Pavlin et al., 2006). Previous research has indicated that traditional sexual health screening often excites embarrassment within a person, as many people report anxiogenic symptoms when discussing genital examinations, describing them as ‘invasive procedures’ (Denison et al., 2017; Bradshaw, Pierce, Tabrizi et al., 2005).
Self-collected sampling is often perceived as being more acceptable and less embarrassing (Bradshaw, Pierce, Tabrizi et al., 2005)., therefore increasing the likelihood of a person screening for STI transmission: young people are less likely to accept screening if they believe that it will inconvenience them (Vaughen et al., 2010).
It is therefore important that, in order to reduce transmission of STIs, traditional sexual health screening strategies are destigmatised, or even replaced, with more confidential and private screening procedures – for example, the SH:24 system provided by the NHS. This is particularly important for STIs that are asymptomatic in nature, such as chlamydia (Balfe et al., 2010).
Hypothesis 11: Undergraduate students are less likely to engage within traditional STI screening strategies, compared to engaging within self-collecting, more confidential STI screening strategies.
Conclusion
Previous epidemiological research has indicated that a combination of demographic and social factors influences the prevalence of sexual risk behaviour. It is, therefore, important that all of the factors that influence sexual behaviour are taken into account during clinical promotion of positive sexual health.
Sex and Relationships Education (SRE) has become a compulsory part of National Curriculum Science at Key Stage 4 (from September 2016).However, academies and free schools are not obliged to adhere to the National Curriculum (Public Health England, 2015). With increased education on sexual health in secondary schools, promotion of positive sexual health is more likely. Public Health England (2018) have proposed that, by September of 2020, SRE will be implemented in all secondary schools, regardless of their academic status.
It is therefore likely that, with the development of promotion of positive sexual health within secondary schools, Public Health England’s national reports upon sexual health will generally be more positive, reporting less instances of adverse sexual health outcomes (e.g. unwanted pregnancy, STI transmission).
In addition to the development of promotion of healthy sexual behaviour, SRE should also promote positive substance use. For example, secondary schools should educate students on alcohol use and drug use, and the interrelationship with sexual health. This, again, would help to reduce the frequency of adverse sexual health outcomes experienced by young people and undergraduate students in the UK.
Overall, preliminary research of this study suggested that both societal and demographic factors significantly affect sexual risk prevalence in undergraduate students, with genetic factors such as CD4 count influencing prevalence of such factors. In order for clinicians to effectively reduce adverse sexual health outcomes in undergraduate students, these factors must be further explored. Further research will allow models of sexual behaviour to be constructed, allowing sexual risk of undergraduate students to be identified and appropriately targeted.
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