Sexual health promotion raises a number of dilemmas for health promoters, which will now be considered.
Professionals working in sexual health promotion need to be cognisant of the way in which sexual health behaviour differs from other health-related behaviour (Mussen et al. 1998). Crucially, an individual's behaviour may have a 'direct, immediate and drastic effect on their partner's sexual health' (Mussen et al. p. 241), whether through infection with HIV or causing an unintended pregnancy. Mussen et al. (1998) argue, though, that the emphasis on, in particular, prevention of HIV has restricted sexual health promotion activity to encouraging people to change their sexual behaviour, and that this has been to the detriment of other activities aimed at improving sexual health in a wider sense, thus improving overall health and well-being.
The Government has set specific targets for sexual health promotion (for example teenage pregnancy and STIs), and has identified 'high-risk' groups, such as teenagers, gay men, young adults and black and ethnic minority groups (DH, 1991). However, one of the results of this is that professionals fail to recognise sexual health promotion needs and opportunities in other population groups, such as older newly single heterosexuals. In addition, some government public health strategies, such as Chlamydia screening, have excluded men, and this has been criticised by Hart et al. (2002), who question the wisdom of such a policy, as men have the same risk of infection from Chlamydia as women.
For behaviour change to occur not only does the individual have to understand the message but they also need to believe they are at risk and that behaviour change is therefore worthwhile. Evidence has shown that while health-promotion interventions and campaigns increase people's knowledge of the role of condom use in the prevention of HIV, they have little effect on attitudes and behaviour (McEwan and Bhopal 1991). This is often due to individuals' perceptions that they have a low risk of contracting HIV - this is particularly true of heterosexuals over the age of 35 (HEA, 1994).
A study of the use of the emergency contraceptive pill and sexual risk behaviour investigated participants' perceived risk of HIV, STIs and pregnancy. While the majority of the participants (78 per cent) felt they were at a medium to high risk of pregnancy, 79 per cent felt they were at little or no risk of HIV and 68 per cent at little or no risk of STIs (Dupont et al., 2002). The authors of this study commented on the awkward paradox that making the emergency contraceptive pill more easily available for women to prevent pregnancy could in fact be encouraging unsafe sexual practices.
Probably more crucial is that for most people the role of sex in their everyday lives is not primarily a health concern. Thorogood (1992) argues that sex is more likely to be informed by discourses of pleasure, risk, danger and penetration, and that while these experiences remain unacknowledged sexual health promotion is unlikely to be effective.
This is true of the gay community, where the culture of safer sex that emerged in the wake of the first AIDS crisis has now melted away (Hari, 2005). It is reported that nearly 60 per cent of gay British men had unprotected anal sex in the last year.
Part of this seemingly cavalier attitude to safer sex lies with the belief of some gay men that contracting HIV is a minor inconvenience that can be treated effectively, leading some HIV experts to label the new treatments 'protease dis-inhibitors' (DH, 2001; Hari, 2005).Again managing these perceptions is crucial if sexual health promotion is to be successful.
Vital to any discussion on sexual health promotion is the complexity of sexual relationships and issues of power and trust within those relationships. Aggle-ton and Tryrer (1994) argue that for health promotion to be effective it is necessary to address the wider issues of oppression, gender inequalities, distribution of power and cultural expectations. Discussion has already alluded to the fact that sexual health decisions normally involve more than one person. Often individuals do not freely make choices about their own sexual health, for example over condom use. This is particularly true of young women's difficulties in negotiating safer sex, in which the partner's preference of method is important. Holland et al. (1990) found that young women often had a negative view of condoms as a form of contraception, as they were unacceptable to their current partners, while using the contraceptive pill became a symbol of their 'love and trust' for their partners. At the other end of the lifespan, older heterosexual couples often resist listening to safer sexual messages, as this would challenge the love and trust within their relationships.
DIFFICULTIES IN GETTING SEXUAL HEALTH MESSAGES ACROSS
It is often difficult to target health messages to specific groups, as individuals have different attitudes to their own sexual health, which are influenced by their own needs, self-esteem and peer norms (Mussen et al., 1998). This is complicated still further in that sexual health behaviour does not occur in isolation, but involves at least one other person, and such a person may have differing sets of needs and values.
This is particularly an issue for teenagers, where the adult world bombards teenagers with sexually explicit messages that give the impression that sexual activity is the norm. At the same time, the reaction of many 'adults', including parents and public institutions, to teenage sex is one of embarrassment or (worse) silence, in a mistaken belief that if sex is not talked about it won't happen. The result, for the Social Exclusion Unit (1999): 'is not less sex, but less protected sex'.
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