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HIV and Sex Work: The Lancet Series

28 Jul, 14 | by shaworth

This week saw the publication of the new Lancet series, an ongoing series of analyses of research in HIV with a focus on identifying those at risk and collating the data on prevention strategies. Previous parts of the series have looked at men who have sex with men (2012), and general prevention strategies (2008); however the latest part of the series is a detailed look at the burden of HIV prevention in sex workers.

The series is a detailed look at the studies detailing the HIV burden in sex workers who are female, male and transgender, and as such, gives a fairly broad look at the subject area. It identifies the barriers that are faced in attempts to reduce HIV incidence in this population, and it’s clear from the review that decriminalisation of sex work in order to reduce human rights violations and protect sex workers is a key part of the HIV prevention strategy. For many years, sex workers have been marginalised in attempts to prevent HIV, but it is obvious from the high disease burden in this group that sex workers need to be brought into the centre of HIV prevention strategies.

A particularly interesting part of the report concerning female sex workers comes from a representative of the Dutch police force, who discusses the change in legislation that has decriminalised sex work for those adults who are working voluntarily in this sector, allowing the police to focus their efforts on investigating human rights violations against sex workers and children who are working illegally. The fact that they are still unable to effectively target sex workers who are working illegally in the country remains a point of concern, but it’s hard to doubt that the decriminalisation does allow them to focus their efforts to protect those who chose to be employed in this way.

What’s also fascinating about the series is the study of male sex workers, and the findings that not all of these men identify as gay, potentially undermining public health strategies targeting this group that effectively make this assumption. The understanding of the driving factors behind the choice of these men who have become sex workers is paramount at identifying successful HIV prevention strategies. There’s also a short appendix of local terminology for male sex workers, which may be useful for those looking to work in sexual health abroad.

The inclusion of transgender individuals in the study makes for harrowing reading. Transwomen (the study does not include transmen) have a disproprotionate risk of HIV infection, 13.5 times the risk for natal women. The lack of research in this area, along with a lack of research into effective strategies to prevent HIV in this population undermines our efforts in this area, which is obviously not an acceptable situation to continue.


Coming Over Here: UK and Overseas Sperm Donors

29 Jun, 14 | by shaworth


Sperm donor anonymity was revoked in the UK in 2005, meaning that children born from donor sperm can now trace the identity of their genetic father at the age of eighteen. The same is true of egg donors. The reverse was not true at the time of the change, with gamete donors being unable to request information about any children they may have assisted in the production of; however cases have since been presented to court from sperm donors who are known to the recipient couple seeking access to the children they have produced.

This week there have been articles in the press about the perceived fall in UK sperm donors since the 2005 legislation was introduced; although few are able to prove this allegation, despite the data being available. All fertility clinics in the UK are regulated by the HFEA, who require registration data on all donors whose samples can be used to artificial reproduction techniques (thus excluding those whose samples are donated to research). In 2011, around 2,000 women received donor insemination and over the last few years, the number of embryos produced from donor procedures has remained steady; although this does not, for some reason, include ICSI procedures where sperm is directly injected into an egg, cultured and reimplanted, which somewhat muddies the waters.

In fact, contrary to the media reports, the number of new UK donor registrations with the HFEA has been rising steadily since 2005. New sperm donor registrations were actually lower in the year preceding the anonymity revoking than any other year since 1992. When the figures are broken down by UK and overseas donors, there has actually been a steady increase year-on-year since 2005. Yes, in 2005 1:10 new donors were from overseas, and in 2010 it’s 1:4, but over the same time period the UK new donor registrations have increased by a third, and overseas donors have increased four-fold, rather than a drop in UK donors and overseas donors making up a shortfall.

Of course, the data available to the public goes up to 2011, and it’s now 2014, so it’s possible that data has been selectively leaked to people who are not your humble blogger, and perhaps ICSI requests have risen stratospherically so that we can’t keep up with demand; although that wouldn’t explain why everyone is so quick to blame legislation that’s nine years old on a three year old phenomenon. Perhaps, the story here is not about a looming sperm-famine, but that you can make some good headlines out of unresearched articles produced with a mere flick of the wrist.

Review: The Menopause Exchange

9 Jun, 14 | by shaworth

The Menopause Exchange is an independent organisation founded by Norma Goldman, a pharmacist with a special interest in health promotion, to provide impartial information for patients and health professionals about the menopause. Information is circulated largely through the quarterly newsletters, which are free and through the Menopause Exchange blog. They are also present on Twitter and Facebook. Unlike some other magazines aimed at patients, they are not supported by advertising, and take no funding from sponsors; although there are no conflict of interest decelerations from the writers.

I read the Spring 2014 issue of Menopause Exchange which covers a diverse range of issues from irregular peri and post menopausal bleeding to the NHS screening programs available for women who are going through the menopause. There is also an “ask the experts” section where questions can be posed to those writing for the newsletter which explore fairly diverse subjects such as the length of time HRT can be used, to complementary and alternative therapies.Although Menopause Exchange states that it is for both patients and health professionals, the articles seem to be mainly aimed at the former rather than the latter. This is no bad thing, as patient support and resources are valuable to those experiencing menopause. The articles communicate the concepts they explore well, without jargon.

Whilst the information produced is good quality, the format of the newsletter could be improved. Digital media has leveled the playing field for communicating information, and high quality printers to produce slick and effective print media are available for home use, but Menopause Exchange isn’t taking maximum advantage of this and I felt that the look of the newsletter was dated. Back issues of the newsletter are available by post, paid by cheque (there is an option to pay digitally, but this doesn’t seem like the first choice), which seems absurd in 2014; although perhaps demand has produced this need.

Overall, I’d say that Menopause Exchange has a lot to offer your patients, and mine. If it took full advantage of technological advances, it would find itself a unique and valuable resource.

FSRH Welcomes Nurses at a one day conference

24 May, 14 | by shellraine, e-Media Editor


The FSRH is delighted that from January 2014 nurses are Eligible to become members of the FSRH and to undertake training for the Nurse Diploma in Sexual and Reproductive Health Care (NDFSRH), the Letters of Competence in both intrauterine devices and subdermal implants and the postgraduate qualification in medical education. The organising committee has planned this ‘one off’ meeting to update delegates on FSRH qualifications and to provide a general update on contraception, together with a motivational speaker on communication skills. This event is aimed at all nurses working in sexual and reproductive health in any setting, service managers and lecture practitioners.


Royal College of Obstetricians and Gynaecologists

27 Sussex Place, London, NW1 4RG

 Course Fee £130.

For Nurse Diplomate & Associate members £120

Please make cheques payable to FSRH and send to

Faculty of Sexual and Reproductive Healthcare, 27 Sussex Place, London, NW1 4RG

Full programme




New Guidance From DoH On Abortion Provision

23 May, 14 | by shaworth

New guidance was issued today by the Department of Health in relation to the provision of abortions in England and Wales. Following an independent, covert investigation by the UK newspaper The Daily Telegraph, concern was raised that abortion was being provided in the UK out with the provisions of the Abortion Act, andwhich would obviously be illegal. The reporter for the Daily Telegraph accessed two abortion providers attempting to seek abortion on the basis of fetal sex alone, which is not grounds for termination in the UK and the latest guidance has clarified that this would be an illegal act.

The guidance doesn’t change the law on termination, but is designed to clarify the interpretation of the rather vague conditions specified. Most “social” terminations in the UK are performed under Category C of the Abortion Act which states The pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman. The guidance clarifies that fetal sex alone does not qualify as a valid reason.

The new guidance also does not remove the condition that two doctors must consent to the termination of pregnancy, and in particular, addresses the issue of “pre-signed” forms and whether or not it’s acceptable to have a verbal history from a colleague prior to signing the form: it’s not. According to the clarified guidance, the opinions of each doctor must be formed individually, and viewing the second signature as a “rubber-stamping” exercise goes against the principles of the act.

In addition to the new guidance, the DoH also produced the results of their analysis of the UK birth sex ratios, after the requests for termination of pregnancy on the grounds of fetal sex called in question whether or not the UK is affected by the phenomenon of “missing girls”, something which is well-described in other countries where a higher social value is placed on male children, resulting in female infanticide and termination of pregnancies on the basis of fetal sex. The results suggest that the UK is not affected, even when the results are broken down to assess the ratios on the basis of the ethnicity or country of origin of the mother.

Currently, to terminate a pregnancy on the grounds of fetal sex, the fetal sex must be identified prior to making this decision. Invasive testing such as amniocentesis and chorionic villus sampling have the risk of fetal loss, and ultrasound assessment is user, and fetal position, dependent. As access to these tests become more widely available, and uptake increases, the sex ratio imbalance gets worse in affected countries. It remains to see what effect the development of commercial testing for free fetal DNA in maternal plasma has on this problem. Currently it is possible to ascertain fetal sex for a £400 test from maternal blood, available on the NHS in a limited capacity for reasons such as congenital adrenal hyperplasia. It remains to be seen, as costs for these tests drop over time, what affect this has on fetal sex ratios. Readers of speculative fiction may wish to consider Ian MacDonald’s River of Gods for an exploration of this phenomenon, and the social consequences, in a near future India.

Sexual Health Organisations Put Pressure On Politicians Before Polls

18 May, 14 | by shaworth

England goes to the polls for its local elections on May 22nd, and leading sexual health bodies are challenging politicians to commit to investing in Sexual and Reproductive Health. The combination of BASHH, BHIVA, Brook, FRSH, FPA, MEDFASH, Terrence Higgins, the National AIDS trust, and the National HIV Nurses Association issued a joint statement:

“Sexual and reproductive health and HIV is an important issue for the whole electorate. In February 2013, the Department of Health published a Framework for Sexual Health Improvement in England which set out a series of ambitions that, if achieved, would ensure everyone has the information, support and services they need to lead healthy lives.”

“We call on all those standing for election to provide leadership to achieve these ambitions and to commit to support investment in sexual and reproductive health, including access to all forms of contraception, HIV prevention and testing, and support services.”

Readers will remember that sexual health services in NHS England went out to tender earlier this year. Local services may wish to address their potential representatives about these issues in hustings, or to contact them during free communication sessions locally regarding their commitment to sexual health provision.

Abortion In The Media

9 May, 14 | by shaworth

In the last two weeks, abortion has been making the headlines again. Firstly in the UK, as glamour model Josie Cunnigham revealed that she was pregnant and subsequently considered an abortion. She spoke openly about this decision in a video interview for UK tabloid The Mirror, and stated that her existing commitment to appearing in Celebrity Big Brother (a long-running reality television series in the UK and several other countries, where contestants live in a house for seven weeks under constant scrutiny of an audience watching them via edited summaries) which she considered to represent a major media break that could positively affect her career.

Cunnigham previously came to public attention when she disclosed that she’d sought a breast enlargement funded by the NHS in order to become a glamour model, and has also openly spoken about seeking cosmetic dentistry using the NHS whilst pregnant, as dental care is free to pregnant women in the UK.

Reaction to her public decision, and her decision to consider an abortion to pursue opportunities to further her career have been divided. She has been the subject of vicious hatred on social media; although the endemic nature of death threats to women in the public sphere via social media makes this feel less threatening as we become jaded with the tweet-now-think-later generation. It’s difficult to ascertain if this is due to the issue of the abortion alone, or whether opinion of her character as someone who works in the sex industry is part of this. There are those who consider her actions to be purely exploitative, aimed at maximising media attention by courting a controversial subject, something that perhaps has grounds given her career is dependent on fame; although abortion is a topic that few UK politicians touch given the divided, and often violent difference of opinion on the subject.

The decision faced by Cunnigham is not one never-before faced by humankind. Professional women have to make decisions about the direction of their career, and it’s obvious that for women who find themselves with an unplanned pregnancy, that these will form part of the decision. Fundamentally, is Cunningham’s decision to consider abortion in her circumstances different from the doctor on the brink of starting a research fellowship? Or a young woman about to start her nursing degree? If she was fashion model on the runway, instead of a glamour model, would this make us feel different?

The second abortion story hitting the headlines concerned Emily Letts, an abortion counsellor who found herself unexpectedly pregnant. She decided to proceed with a surgical termination, not performed with general anaesthesia, and subsequently decided to film the experience. Undergoing surgical termination under local anaesthesia, the short video focusses entirely on Letts’ face for the duration of the procedure.

Letts is not the first to document her experience of termination. In 2012, an anonymous women secretly photographed the procedure to use on a website she’d created called This Is My Abortion. She subsequently wrote about this decision in UK newspaper The Guardian. Speaking about her experience, she wished to counter-argue the graphic images used by pro-life protesters, whose vitriol she experienced attending the local clinic, as she felt realistic images of abortion were difficult to find.

Predictably, both Letts and her anonymous forbearer received a mixed reaction. One on side they were touched by messages of women who’d experienced abortions and who were glad that someone had taken the time to document the reality of their experience, and also messages of support from women who had been forced to seek illegal abortions in countries where abortion is not legal. On the other where those who felt that the decision was flippant, and of course not in keeping with their pro-life views.

She has a point. For those of us advising and consenting women on abortion procedures, where can we find such intimate information to advise women on the reality of the procedure that focuses on what they should expect to experience? Women who wish to birth in a hospital in the UK can take tours of the unit so that they know what to expect, and there are countless examples of videos of gynaecological surgery on the internet for those wishing to know the intricacies of their chosen procedure. Why should we treat the procedure of abortion differently?

The experience of Letts and Cunningham revives the debate as to whether a woman’s body is something only she has the right to control, with the base population of the internet vying largely for the right to choose for them. It only takes a short glance at some of the particularly vile commentary to be sure that they are the party that we can clearly say do not deserve the decision to be recognised as people.

Wud U? Reviewing Barnardos’ App For Reducing The Risk of Sexual Exploitation

4 May, 14 | by shaworth

The Wud U? app was launched last month. The result of a joint project by Barnardos and Microsoft, it’s designed to be an educational tool for young people and professionals who work with them. It’s aimed at helping young people identify behaviours that may put them at risk of sexual exploitation.

Produced after extensive interviews with young people who had been victims of sexual exploitation, the app presents three scenarios, duplicating them from the point of view of male and female protagonists. You can read through the stories and make decisions for the characters, with feedback from the app as to whether these were sensible or not. If you decide to avoid a situation in which sexual exploitation takes place, the app has the character make the other choice, with the caveat that your decision would have been better in retrospect.

The decision to use the same story but reverse the sex of the protagonist is a nice touch, as the lack of standardisation of sexual education in the UK curriculum has lead to criticisms that it remains overly heteronormative, and attempts to be more inclusive have lead to voices of protests from the usual faith groups. By make the app more inclusive, it’s instantly more useful to more young people, which is great.

Visually, the app looks good, with high-quality illustrations in a modern, graphic-novel style; although this comes at a price: the app is 36MB, which is pretty hefty for what it provides, considering that the slick and addictive Candy Crush Saga comes in at 32MB. Although the app is free, it’s worth noting that using PAYG data prices from a main UK provider, the true cost of this app would be £18. Professionals requesting that young people download the app for teaching purpose should suggest that they do so via a WiFi connection.

Criticisms of the app have so far centred around the fact that some older teenagers may find the language of the app patronising. I’m in partial agreement with this; although I do think that simplifying the language keeps it accessible to those with literacy problems, but this comes at a price. I found one particular sentence, where the behaviour of those who exploit young people sexually is described as “clever” to be uncomfortable, as I think this is a word that has positive connotations. “Devious” would have been more appropriate, in my opinion, but this might have been rejected to keep the reading age on target.

Personally, I think there’s a different problem with Wud U? The app never clearly makes the point that the sexual exploitation of young people is wrong, and ultimately that the blame for the exploitation lies in the hands of those who are orchestrating the exploitation. Instead, by focusing entirely on the actions of the victims and extrapolating how their decisions have resulted in the situation in which sexual exploitation has taken place, it seems to place the responsibility of the exploitation on their shoulders. Whether this is intentional or not, and I doubt that an organisation like Barnardos sets out to victim-blame, I think a concession has to be made that sexual crimes don’t exist in a cultural and social vacuum. Last year, Robert Colover was suspended after commenting, during a trial that he was presiding over, that the thirteen year old victim was predatory , and criticisms of the handling of child sexual exploitation in Rochdale highlight that the young people involved were made to feel responsible for being victims of sex crime.

In an ideal world, an app like Wud U? would be no different to the signs in car parks suggesting that you hide your sat-nav to reduce the risk of a break in, but the fundamental difference between those two situations, is that if you report the theft of your sat-nav to the police, you can be sure that it will be taken seriously as theft, and that no one in court that by having a sat nav in the first place, you were in some way inviting the break in.

Wud U? makes little concession to this situation, and as such, I find that it falls short of what it could achieve. At the end of the stories, we never find out what happens to the perpetrators of the exploitation, only that the victims are being supported by Barnardos. By giving this repeated viewpoint that nothing will be done to prevent this happening again, and that the perpetrators will go unpunished, I’m left feeling that the situation is hopeless, which is opposite to the feeling of empowerment that the app is supposed to give me.

IPPF Says World Bank Failing To Commit To Reproductive Health Issues

19 Apr, 14 | by shaworth

A recent report by the International Planned Parenthood Federation (IPPF) criticises the World Bank for failing to increase its commitment to funding projects related to reproductive health. There are 222 million women whose needs for family planning remain unmet, and this figure is projected to increase to 900 million by 2015. The World Bank provides a major source of finance for health projects and services around the world, and so has an in important role to play in improving access to family planning services.

IPPF have produced a scorecare which will track the commitment and progress of the World Bank’s involvement in reproductive health issues. “The scorecard revisited: Monitoring and evaluating implementation of the World Bank’s Reproductive Health Action Plan 2010–2015” reveals that, since the introduction of the Reproductive Health Action Plan in 2010, the original ambitions have not been fully realized.

White Ribbon Alliance champion, Princess Sarah Zeid of Jordan said: “Women and men all over the world tell us that they desperately need ways to space the births of their children, to ensure not only the health and survival of mothers and newborns, but the prosperity of their families and communities. The international community recognizes the critical importance access to contraception plays in advancing equity and development around the world, and we applaud the on-going efforts of governments, organizations and civil society to ensure the rights of all women are realized.”

IPPF Director General, Tewodros Melesse speaking of the need to measure the World Bank’s efforts on reproductive health added: “We have a role to ensure that investment and programming are targeted efficiently and according to the different realities on the ground. Worryingly, our tracking shows that Bank’s new investments towards reproductive health for 2013, declined from 2012, both in absolute terms and as a percentage of the Bank’s total health budget. Reproductive health investments in 2013 made up 7% of the Bank’s total health budget, compared with 24% in 2012. If the Bank does not increase its new commitments to reproductive health in coming years, there is a risk of seeing a downward trend in the Bank’s future funding. This would be detrimental to a country’s ability to strengthen their health systems for people in poverty.”

“The Bank has a vital role to play in creating demand for essential reproductive health services for people. We remain optimistic that the Bank can turn around its performance by increasing the level of their investment in years to come and committing to a new reproductive health strategy from 2015”

Jackson Chekweko, Executive Director, Reproductive Health Uganda, IPPF Member Association said: “We need to see investment. This will ensure continued improvements in reproductive health outcomes on the ground for countries most in need of investment. It will help to accelerate progress on Millennium Development Goal 5, where least progress has thus far been made.”


UN Fails To Resolve Action On Ending Discrimation Based On Sexual And Gender Identity

18 Apr, 14 | by shaworth

The UN’s Commission On Population and Development  ended its 47th session in New York last week with the recommendation that the promotion of gender equality, reproductive health and rights are key priorities for sustainable development. The weeklong Commission was convened at the UN headquarters in New York to assess 20 years of progress since the ground-breaking agreements made at the International Conference on Population and Development (ICPD) in Cairo in 1994.

IPPF Director General Tewodros Melesse said “At this critical juncture in the post-2015 process, governments have renewed the commitments made in Cairo in 1994 and since. The right to control one’s fertility and sexuality is fundamental to social and sustainable development and governments have agreed it should be a core part of the next development agenda. Now we need strong leadership from governments to lead us into the next fifteen years.”. The Millennium Development Goals expire in 2015, and the Commission hopes that by integrating these key areas into development policy, that they will keep the human rights of women and girls at the top of the agenda.

Fifty-nine of the represented countries called for action to end discrimination and violence on the basis of sexual orientation and gender identity, and many expressed strong support for advancing sexual rights; however a small, yet vocal group of countries blocked language on sexual rights from the final agreement.

Governments will reconvene in September at the UN General Assembly to renew political support for the actions required to achieve the goals of the ICPD program of action.


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