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Essay, 35 pages (9000 words)

The sexual health needs of men who have sex with men in bath and north east somerset

[pic]Bath and North East SomersetMen??™s Sexual Health ServiceThe Sexual Health Needs ofMen who have Sex with Menin Bath and North East SomersetAMSexual Health Development WorkerTDService ManagerJune 2010ContentsBackground and Introduction3Methodology5Demographics11Age Ethnicity Area of Residence Sexual Identity Employment and EducationThe Scene14The Scene in Bath and North East SomersetThe Scene outside of Bath and North East SomersetCurrent Sexual Health Service Provision17GU MedicineCaSHGPsOther Services27THTYouth ServicesProject 28School Health NursesSAFEQuestionnaire Results29Annex A ??“ Questionnaire54Annex B ??“ Glossary of Terms and Abbreviations59References used in this Report61Executive Summary63Background and IntroductionMen??™s Sexual Health has been working in Wiltshire and Swindon since 1996 to promote greater awareness of HIV and other sexually transmitted infections within Men who have Sex with Men. The organisation was requested by Bath and North East Somerset PCT to provide a pilot service across Bath and North East Somerset, where the emphasis on the work was with the Gay and Bisexual Male community, and included all Men who have Sex with Men, irrespective of their self identified sexuality, during the period June 2009 to May 2010. Part of this pilot was to carry out the first sexual health needs assessment in Bath and North East Somerset targeted Men who have Sex with Men (MSM), which included gay and bisexual men.

Although data has previously been collected by Men??™s Sexual Health for the Sigma Researches National Gay Men??™s Sex Survey on an annual basis, this was the first targeted assessment in the area. This report aims to provide information specific to Bath and North East Somerset to inform the Primary Care Trust and other providers of the requirements to meet the needs of Men who have Sex with Men and to direct future work towards any needs that were identified as unmet, or met only in part. In terms of the Baths gay scene, when this assessment was carried out there was only one active gay pub in Bath where some of the recruitment was carried out. There was also a weekly coffee morning (Gay West), two Bath University Student Union Lesbian, Gay and Bisexual Societies and a commercial sauna type venue (the Suite). There is very large gay scene in Bristol, the only other large city in the region, which is only 12 miles from Bath. This was not covered in the data gathering for this needs assessment, but in the future it would be prudent to include an element of data regarding Bristol in the data gathering.

In 2001, the Department of Health published The National Strategy for Sexual Health and HIV to address the rise in sexually transmitted infections and HIV. This strategy highlights that ??? sexual ill health is not equally distributed among the population??™, specifically Men who have Sex with Men were identified as a high risk group. This is supported by research carried out by Hickson, et al (2003)[i] which showed that of the gay men surveyed only 60% used a condom during their first experience of anal sex. The survey also showed that of those that had anal intercourse in the last year, 48. 8% had unprotected intercourse and 59. 6% of those who had, had both unprotected insertive and receptive intercourse. This assessment aimed, in part, to investigate the sexual behaviour of Men who have Sex with Men in Bath and North East Somerset and whether the trends identified in the Hickson et al research applied. The national strategy for sexual health and HIV also highlights the need for ??? up to date evidence of what and how different interventions work??™.

This assessment aimed in part to evaluate the interventions already in place within Bath and North East Somerset and to asses any unmet sexual health needs. This evaluation will also help to inform Bath and North East Somerset Primary Care Trust of the future potential direction of work to best meet the needs of the target groups. This research also seeks to examine the other health related services accessed by gay and bisexual men in Bath and North East Somerset. The aims of the study can be summarised as: ??? To identify the demography of the gay and bisexual population to which Men??™s Sexual Health is delivering services. ??? To assess the work which Men??™s Sexual Health and other providers have already done in the area.

??? To find any gaps in the coverage of Men??™s Sexual Health and to identify any services for which there is a need but no supply. MethodologyTarget GroupThe primary target group for this report is defined as Men who have Sex with Men; this can be defined as including: Gay Men This group self identify as being homosexual both sexually and behaviourally. Traditionally it is this group that people assume are the only MSM population. Government figures believe this group accounts for between 2 and 6% of the general population, increasing to 10%+ in highly urbanised areas (such as Central London)Bisexual This group can self identify as being either heterosexual or homosexual in behaviour, and can have sexual partners of either gender. It is believed (though never formally quantified) to account for a further 13% of the population (Based on estimates by groups such as Stonewall). However, according to Kinsey2 to qualify as bisexual a male would need same gender sexual contact on at least two occasions in any given yearHeterosexual This group self identify as being purely heterosexual in behaviour, but can homosexual in sexual behaviour. They are always very hard to identify, and very hard to reach, as often, due to religious or cultural differences, they do not self identify as anything other than heterosexual, and will be highly resistant to any suggestion that their sexual behaviour is homosexual.

There are no figures as to how many fit into this category, but it has been suggested that in urban areas this could be as high as 3%Trans This group can self identify as either male or female, and further can identify as being heterosexual or homosexual. They can fall into Transgender, Transsexual, or cross dressing. As a rule they are very private individuals, and numbers are not known or fully understood, however, it is believed that transgender (pre and post operative) account for 1 in every 11, 500 in the UK, but within this group that does not allow for any knowledge of sexual behavioural identity. Consequently it is currently impossible to quantify the number of Trans people in any area. Men who have Sex with Men This is the generic term for any man who has sex with any other man. It encompasses all the above groups, so could (in highly urbanised areas) account for around 25% of the male population. When one considers the original Kinsey Report[ii], he estimated that 37% of males had reacted sexual with other males, and in 1979, after extensive re-investigation, Gebhard[iii] concluded that 36. 4% of males could be deemed to fit the MSM categoryQuestionnaire DevelopmentThe questions that were used in the questionnaire were in part identified from a number of sources, including questions from other organisations needs assessments, including from the staff at the Sheffield Centre for HIV and Sexual Health in Sheffield.

A number of the questions for the survey came from Hickson et al (2003b)[iv] and the Census (2001), using questions from these sources facilitated establishing comparisons with other similar populations. Before being used, questionnaires were piloted on a small number of the target population for assessment. From this process, many of the questions were reworded and the layout changed to facilitate completion. The scale that was used for socio-economic status is the Registrar General??™s Classification of Occupations taken from Breakwell et al (1995)[v] and Wetherburn et al (1999)[vi]. There are other scales that could have been used but these scales were considered sufficient for this report. Exclusions and RecruitmentThe criteria for excluding data were decided upon in a number of ways.

Firstly it was deemed that if a questionnaire had been filled out by a respondent of the wrong gender then this should be excluded on the grounds that they are not in the target population. Similarly, if a questionnaire had been spoiled (circling all possible answers for all questions for example), it was also excluded. Data was also excluded if the respondent had answered less than 25% of the questions. Data was further excluded if the respondent had not had engaged in homosexual sex in the past 12 months and had no intention of doing so in the future.

Questionnaires excluded from the results.| Reason for exclusion | Number || Heterosexual | 8 || Wrong Gender | 0 || Less than 25% completed | 3 || Total | 11 | Similarly, a requirement of this assessment was to look at the needs of those who were ordinarily resident in Bath and North East Somerset. It was recognised that there would be a portion that would complete the survey, which did not meet this requirement, so were excluded on this ground. Questionnaires excluded on grounds of residency| Reason for exclusion | Number || Lived in Wiltshire | 12 || Lived in Bristol | 5 || Lived elsewhere | 8 || Total | 25 | RecruitmentRecruitment was primarily carried out face to face at gay pubs and gay venues Bath.

Participants were given a questionnaire to fill out and were asked to place it in a sealed box provided to protect anonymity. This type of recruitment was only carried out within Bath, thus representing the community that use the commercial gay scene in Bath. Using data from the questionnaires it was found that although a high proportion of the sample did live in Bath city, the sample also contained respondents from surrounding localities. To try and broaden the scope of the assessment to cover MSM who don??™t use the commercial gay venues, the questionnaire was handed out at two Public Sex Environments, whenever a man indicated a willingness to complete a survey and return it to us by post, a pre-paid postal envelope was included. The response rate from this source was 18. 8%. The questionnaire was also advertised and available to complete on the Men??™s Sexual Health Website (http://www.

B&NESmsh. org. uk ). This produced 5 completed valid questionnaires (5. 8%)Number of valid questionnaires filled out at the different recruitment venues.| Venue | Number of questionnaires || Mandalyns (a gay venue in Bath) | 52 || Gay West (a Gay Social Group in Bath) | 12 || Web Responses | 5 || Postal | 16 || Total (n) | 85 | Data AnalysisThe data obtain has been analysed by use of Statistical Analysis Software.

All inputs were anonymous and separated to ensure non-biased results. Qualitative Focus GroupsFollowing on from the quantitative element of the survey, it was agreed that some of the responses were unclear, especially as there was some discussion around the differences in age responses. It was decided to hold two focus groups, one with men who attend Mandalyns Bar and the other with those who attend Gay West Social Group. All were drawn from survey respondents who had indicated a willingness to be contacted again. All were offered the chance of either a face to face contact, telephone or focus group, all were happy to attend focus groups. The choice for the two groups was based on the demographics of the venues; Mandalyns primarily attracts those under 45 whilst Gay West attracts those over 45. Consequently two focus groups were arranged and facilitated, and where appropriate these have been incorporated in the relevant parts of this report.

Numbers attending Focus Groups| Venue | Number in Focus Group || Mandalyns (All aged 45) | 6 || Total | 13 | Time FrameThe initial quantitative assessment was carried out over a six week period of time and the qualitative assessment carried out over the following six weeks. (12 week in total)EthicsDiscussion took place with the Sexual Health Commissioner and consequently advice was sought from the Research Governance Lead at B&NES PCT. We were informed that the need for formal ethical approval for this survey was not necessary as it was designed to gather information around behaviour, knowledge and existing services, rather than exploring a potential new service or capturing identifiable personal information. With regards to completed questionnaires it was agreed that these would be destroyed on the completion of this report. Sampling FrameThe individuals targeted for this assessment were Men who have Sex with Men (MSM), irrespective of their self identified sexuality. Based on data provided by B&NES PCT Public Health team, there is an estimated minimum of 1, 677 and a maximum of 5, 030 (self identifying) gay men, which is based on an estimate of between 2 and 6 percent of the population. Estimates of sexual orientation of Bath and North East Somerset residents – 2008| | Sex || B&NES | 85 || Out of Area (Discarded Results) | 8 | Whilst carrying out this assessment a number of respondents were from areas outside of B&NES, these were not included in this report. Consequently 100% of respondents in this survey are ordinarily resident in B&NES.

Sexual Identity:[pic]Due to the nature of the assessment care was taken to only engage with the male population that self identified as gay, bisexual or MSM. All were given the opportunity to self identify their sexuality, and 84 self identified as fitting the assessment group, 1 self identifying as ??? other??™, but indications from the survey responses indicated that they significantly engaged in MSM contact, so was classed as a valid responseOccupational Status:[pic]The majority of individuals who completed the questionnaire identified as having an employed (44%) occupational status with the remaining individuals being Unemployed (1%) Self Employed (5%) Retired (19%) Student (32%) and other (0%)The numbers surveyed indicated a higher response from employed than in other comparable surveys; we can only assume that this could be a result of the localised socio-economic conditions rather than other reasons. THE SCENEThe Scene in Bath and North East SomersetThe scene in Bath and North East Somerset is quite small for a city the size of Bath. Many of the older advertised venues have closed in the past few years, due either to management changes or due to trading difficulties in the current economic climate. Outside of the city of Bath, there are no venues within B&NES. ??? Mandalyns Public House (Public Social Venue)The only public venue in Bath is Mandalyns.

Mandalyns is a gay bar and has weekly events such as karaoke and poker nights that are used to draw clientele in, and even on these nights the numbers attending seem to be around 30-40 people of all genders and sexualities. On other nights the numbers attending tend to be about 15 people, all of which appear to be regulars rather than new clients. The age range of their clientele is 18-30 with a few regulars of an older age group, the majority of the clientele are students at the local universities, and are mixed gender and sexuality. ??? Rainbow Cafe (Membership Social Venue)The Rainbow Cafe is run every Saturday morning in Central Bath by a group of volunteers of a group called GayWest. They are a south west based group predominately from Bath and Bristol, but also from as far afield as Warminster in Wiltshire. They have a membership of about 40 individuals all of whom are gay, bisexual or lesbian and of an older age, primarily 50+. Normal attendance is in the range of about 20 people. ??? The Suite Sauna (Public Sex Venue)The Suite sauna, is primarily accessed by older aged males 40+, predominantly married and categorised as Men who have Sex with Men (MSM).

This group is very different; they keep themselves to themselves and don??™t interact outside of the venue as it??™s a very private and personal place for them to go to. The Suite changed management just before the start of this assessment and the current management are not welcoming of health interventions in the premises as they feel it will scare clientele away, thus affecting the profitability of the venue. Consequently we were not able to access any of the clientele who use the Sauna. ??? Night Clubs (Public Venue)All nightclubs in Bath claim to have LGB&T Friendly policies, however many clients who have used them have experienced homophobia to some degree, so tend not to use the Nightclubs in Bath, much preferring to travel to the extensive LGB&T scene in Bristol. ??? University LGB&T Societies (Student Membership Only)Both universities have their own LGB&T Societies, which tend to have predominantly female membership, which is very common of many LGB&T Societies. It is also clear from contact with them, that their Health Promotion needs are very much met from university resources. It was also noted that both societies had a resistance to contact with outside agencies, much preferring to work within and to support themselves. The Scene outside of Bath and North East SomersetThe majority of gay and bisexual men from Bath, travel into Bristol, to attend the Gay Scene there, as they consider that scene in Bath is to small and conservative in nature.

Bristol??™s gay scene is much larger than in B&NES, and encompasses a greater range for tastes, it also allows for a much higher degree of anonymity. There are two main night clubs, The Queen Shilling, and Vibes, which are busy on nearly every night. Additional to the night clubs are a number of exclusive LGB&T pubs, that are ??? straight??™ friendly, each appearing to cater for differing tastes and age groups. For example The Griffin caters for the older clients, whilst The Pineapple caters for younger pre-clubbing groups and individuals. It is also noted that many of the non LGB&T venues in the centre of Bristol, have a strict ??? LGB&T Friendly??™ Policy which allows for a much larger mix of communities than can be found in Bath. Many of these venues already have interventions and health promotion which is provided by THT West, and nearly all carry a stock of free condoms. All venues tend to be quite busy to very busy on most evenings. There is also some indication that a small portion of people from B&NES do not socialise during the week, but travel to London, Cardiff, Bristol or Birmingham at weekends only.

For ??? Non-Scene??™ people there is also a variety of other informal clubs in Bristol, which attract members from B&NES, such as Supper Clubs, Reading Clubs and Cycling Clubs. CURRENT SEXUAL HEALTH SERVICE PROVISIONThis section is to show the current sexual health services available to Gay, Bisexual and Men that have sex with men client group, the levels of access to these services and STI levels within males in B&NES. Each section covers both the prospective of the Service user and the Service Provider, this ash been done to demonstrate both differences in views, concerns and commonalities that may be present, between both the MSM community and the Service Provider.

GU MedicineThe GU Medicine clinic provides STI and HIV testing and STI treatments. B&NES GUM is based at the Royal United Hospital in BathOpening TimesWalk In: Monday, Wednesday, Friday 8: 15am ??“ 11amAppointments: Monday, Wednesday, Friday 2pm ??“ 4pmHIV Clinic: Tuesday 8: 15am ??“ 11amService Users ProspectiveDespite GUM services being the mainstay of any PCTs Sexual Health Strategy, within B&NES it was found that 69% of MSM under 25??™s said they had not heard of the GUM and only 62% of the remainder had accessed services there; thus giving an access rate of only 19. 6% from under 25s MSM. Conversely it was found that 91% of MSM over 25 were aware of the GUM and 82% had accessed the service; 74. 9% of over 25 MSM had accessed the GUM. ??? I don??™t like the GUM, it??™s too impersonal, I want to get treatment not give them a life history??? (24 year old)The greatest concern that was presented was the opening times, of which 33% of respondents indicated that they were not able to access the service due to other commitments.

Many felt that this was not only an irritant (making them find alternative services often out of area) but many also felt that the GUM was preventing them from obtaining the healthcare when it was needed. ??? Why are they never open when I am not working, as I can??™t take time off work to go there??? (22 year old about GUM) ??? OK I went to the drop in session, but was waiting ages, in the end I had to leave to get back to work, or my boss would have fired me!??? (42 year old about GUM) ??? I work 10 hours a day, Monday to Friday, so how the hell I??™m I meant to get there. They need to be open when I can get there ??¦. It??™s meant to be there so we can get there, not when they want us there??? (52 year old about GUM)When MSM had accessed the services at the GUM, by far the majority had felt positive about the service received and had not felt discriminated against in any way. ??? I was surprised how nice the staff were, I never felt as if I had done anything wrong??? (35 year old about GUM) ??? It was nice to be treated like a human??? (42 year old about GUM)There was one other area of concern that seemed to be common regarding the GUM Service, and this was the lack of specific male health specialist for them to talk with (currently the GUM has only one male member of staff and he is one of the consultants).

15% of respondents felt that this should be addressed, and some felt that the lack of male staff could be discriminatory in nature. ??? I go to Bristol; they??™ve got a man I can speak with??? (35 year old about GUM) ??? I hate speaking with women, they make me feel uncomfortable, and why the hell shouldn??™t I be entitled to talk with a man about man things??? (42 year old about GUM) ??? I ain??™t going to talk to a woman about screwing another guy, I just lie to them, they don??™t know any different??? (22 year old about GUM)Other factors that appeared to work against the GUM is that for many MSM, there is still fear about confidentiality, and a fear that they will be recognised by others accessing the clinic. Both of these are unfounded, but on a perception level being recognised in your own community can and does pray on the minds on many MSM. This would possibly account for the fact that a number of MSM travel out of community to receive treatment or for screenings.

This appears to be borne out by the fact that in 2008, 11% of those attending the GUM in Bath were classified as having a homosexual behaviour, where as both the national and local figures indicate a population of about 2% being MSM; this is indicating either local MSM are about 5. 5 times more likely to become infected with an STI, or that a large percentage of MSM are travelling into the GUM at Bath, from outside of the area. This is further clarified by the fact that of the MSM seen at the Sexual Health Clinic (Chippenham) and GUM in Swindon for 2008, 6% indicate a Bath postcode (figures are not available for Bristol, but this is the nearest GUM to Bath) ??? I would go away from here [B&NES] to get an AIDS test, ??? cos you might be seen at RUH, and then everyone would know, wouldn??™t they??? (22 year old)Service Providers ProspectiveThe staffs at the GUM are aware that in some cases they record sexual behaviour from subjectivity, rather than admission by the patients they are seeing. This does lead to a further complication in that the current IT system does not allow changes to this field once it is set. It is recognised that this alone will skew any reporting of figures as it has labelled men who are married and only heterosexual in behaviour as MSM, especially when answers given to questions by patients appear to be ambiguous and avoiding (such as referring to partner rather than wife, and remaining gender neutral in discussion).

However, they also recognise that some of the patients that they see are more than happy to discuss their sexuality and sexual behaviour with them, and feel that this may be due to a community knowledge that that all records are completely secure, and no links are made with other areas, such as GP practices. Access to GU services within Bath and North East Somerset during 2008|?  | Gender | First Attendance | Of which were new | Subsequent attendances || | | | patients | || Total average | Male | 2618 | 1528 | 989 || attendances per 1/4 | | | | || | Of which homo/bisexual | 303 | 121 | 439 || | |(11. 57%) |(7. 91%) |(44. 38%) || Incoming calls for clinical advice or results | 898 |?  || | | | The attendance figures for 2009 are not yet available, as they are subject to normal verification and scrutiny, however, it is understood that though the numbers attending have increased, the MSM percentages remain approximately the same. Latest figures for GUM indicate that appointments are offered to 100% of people contacting the GUM within the required 48 hours, however, due to issues outside of the GUMs control (such as patients work commitments) only 84. 8% of patients are seen within the 48 hour time frame (which is classed as significantly worse than the England Average). GUM is striving to improve on this and it is felt that when the new figures are realised late in 2010, it will show a significant improvement[viii]GUM actually classifies uptake of services by local MSM to be low, but they also recognise that many MSM may be travelling into area to receive treatment or screenings, but they feel that this may be down to a fear of being seen or recognised, rather than an access issue at their own local GUM.

They believe this is in line with national trends noted by other GUMs and may account for about > 10% of MSM from the local area who they are quite certain are not accessing the GUM in Bath. Services provided to MSM by GU Medicine 2008| Services Provided | Total | Homo/Bisexual Total | As Percentage || Sexual Health Screen (no HIV antibody test) | 529 | 32 | 6. 04% || HIV antibody test and sexual health screen | 1504 | 177 | 11. 7% || HIV antibody test (no sexual health screen) | 83 | 16 | 19.

27% || HIV antibody test offered and refused | 595 | 21 | 3. 52% || Hepatitis B Vaccination (first dose only) | 95 | 65 | 68. 42% | When a patient presents they are aware that many profess to have a higher knowledge of STIs, than they actually do have. In some cases this can be very worryingly low, for example the staff are concerned that many MSM under 25 believe that should they contact HIV, then they just need to take a pill, and they will be fine.

Notwithstanding this attitude amongst young MSM, the prevalence of HIV within B&NES remains low at 0. 47% in 2008, which is significantly lower than England4. It is known that many MSM once diagnosed often move to the larger cities such as Bristol, where there are more services available for them to access. Sexually Transmitted Infection Levels in Males that accessed GU services during 2008.| STI | Under 15 | Over the full age spectrum there appears to be a reasonable awareness around services that are available within B&NES, with 58% indicating knowledge of both GUM and CaSH services, with a further 32% indicating knowledge of THT and their services. Of those that have accessed services 70% accessed GUM or CaSH services, and 17% have accessed THT services. When broken down further by age (under 25 and over 25) a clear distinction appears.| | Under 25 years old | Over 25 years old || Aware of service | GUM | 31% aware | 91% aware ||(As a % of those giving a | CaSH | 23% aware | 5% aware || response) | THT | 62% aware | 61% aware || | Safe | 11% aware | 0% aware || Accessed Service | GUM | 38% have used | 82% have used ||(As a % of those who are aware of| CaSH | 12% have used | 0% have used || service) | THT | 58% have used | 37% have used || | Safe | 13% have used | 0% have used | With the age differentiation applied it is clear that there is a clear distinction between the two groups: Those who are over 25 are more likely to access ??? traditional??™ services, and have a higher knowledge of the ??? traditional??™ services.

??? CaSH Is that like a condom machine??? (42 year old)Those who are under 25 are more likely to have accessed ??? newer??™ or non-PCT??™ services and have a higher knowledge of those services. It is noted that 7% of those attending the THT HIV Fast Testing service in Bath have a B&NES postcode. [Source: THT West 2009] ??? I would go away from here [B&NES] to get an AIDS test, ??? cos you might be seen at RUH, and then everyone would know, wouldn??™t they??? (22 year old)A majority of under 25??™s (69%) have indicated that they have not heard of, or accessed, GUM services, when asked the reason why they had stated that there were alternative services that they preferred to access, however, there is no evidence that they are accessing other services. ??? I don??™t like the GUM, it??™s too impersonal, I want to get treatment not give them a life history??? (24 year old)A very high number of people under 25 years of age (89%) were unaware of the SAFE brand, but when discussed with them they already had access to free condoms via the various venues that they attend, so felt that SAFE would not be of use to them. Most notable is that percentage of younger people that are accessing non PCT services, such as THT (58%), which may or not result in referral into other services.

??? I??™ve used them [THT] and they have told me to go to the clinic in Cardiff, that way I won??™t risk being recognised??? (22 year old)In the under 25??™s there is a poor knowledge of GUM (69%) and CaSH (77%), but a higher knowledge of THT (62%), this is attributable to the publicity and visits by THT into B&NES, such as leaflet distribution and previous PSE outreach. It is recommended that: ??? Further information and education around the range of available services within B&NES is targeted in a proactive manner aimed at the MSM population. ??? That the information be tailored to suite the age ranges, rather than being generalist in nature. These recommendations are based on the fact that there are no targeted resources provided by any sexual health service from B&NES to the MSM community and that when looking at age differentials it is clear that not all services are known to all age ranges. There is also clear indication that those under 25 are relying more in internet based information, whilst those over 25 are tending to use more traditional (literature) based information. Q2.

How would you rate the service you received on a scale of 1-5, 1 being poor and 5 being excellentThis question was asked to gain an overall indication of how people who had accessed services in B&NES felt about the level of service they received. The scale chosen relates to the equivalent of a star rating. In total 100% of people who had accessed services gave a response to this question.

| 1 | 2 | 3 | 4 | 5 || 0% | 0% | 33% | 25% | 42% | Overall the satisfaction rating was equivalent to a Four Star Rating, with a bias towards Five Star. On follow up questions with those that agreed, some of the comments were: ??? I was surprised how nice the staff were, I never felt as if I had done anything wrong??? (35 year old about GUM) ??? It was nice to be treated like a human??? (42 year old about GUM) ??? I found them hard to get hold of, but when I did they were OK and dealt with me OK??? (22 year old about CaSH)Overall it appears that the Services within B&NES rate as a 4-Star service, and that people who use them are satisfied with the service they have received. Q3. What improvements (if any) could be made to the service you receivedIn total 100% of people who had accessed services gave a response to this question.[pic]The largest request was for more access to services (33%), and when followed up the key issues revolved around being able to get to the initial and follow up appointments so that they tied in other commitments.

??? Why are they never open when I am not working, as I can??™t take time off work to go there??? (22 year old about GUM) ??? OK I went to the drop in session, but was waiting ages, in the end I had to leave to get back to work, or my boss would have fired me!??? (42 year old about GUM) ??? I work 10 hours a day, Monday to Friday, so how the hell I??™m I meant to get there. They need to be open when I can get there ??¦. It??™s meant to be there so we can get there, not when they want us there??? (52 year old about GUM)The second most requested service was for faster testing and results (25%) and many felt that as these were becoming more and more accessible in places other than GUMs, CaSH, etc., that these should be offered as ??? standard??™ at all clinics. It was especially felt that as organisations such as THT could offer one hour testing for HIV that this should also be offered at NHS Clinics in B&NES.

??? Why the hell should I have to sweat for days to get the results from an AIDS test when I can go to Bristol and get it done in one hour??? (33 year old) ??? When will the RUH grow up and realise that they can keep us waiting for days for results, you can get them same day or even in one hour in other clinics. Last test I had was at a clinic in Gloucester, got tested in the morning and had all the results back in the afternoon??? (53 year old) ??? I had an HIV test in Supadrug in Brighton, why can??™t we have this in Bath, it means I could get tested in my lunch hour??? (24 year old) NOTE: These are now commercially available in some Supadrug stores and cost the customer ? 79. They are using the BioLytical 1 Minute HIV-1/HIV-2 Insti Antibody testThe third most requested change was for a male member of the nursing team (15%), and many felt that this was a bar to them ??? being comfortable??™ with the service or even accessing the service.

With those requesting this change, on following up, all indicated that they went out of area to alternative services to be able to speak to a male member of staff. It was also noted that this group also accounted for the two responses for less judgemental staff. ??? I go to Bristol; they??™ve got a man I can speak with??? (35 year old about GUM) ??? I hate speaking with women, they make me feel uncomfortable, and why the hell shouldn??™t I be entitled to talk with a man about man things??? (42 year old about GUM) ??? I ain??™t going to talk to a woman about screwing another guy, I just lie to them, they don??™t know any different??? (22 year old about GUM)It is recommended that: ??? The opening times of the GUM service should be looked at to make them more user available, such as two evening sessions per week.

??? Consideration is given to adopting the faster testing methodologies that are now becoming more prevalent within the commercial sector. ??? Where possible a male is present at selected (and advertised) clinics to encourage more male attendance. Q4. Have you ever taken part in a sexual health screening /testing| Yes | No || 62% | 38% | With an overall figure of 38% indicating that they have never tested, this is in line with other research where nationally the figure is also 38%[xvii]When broken down further by age (under 25 and over 25) a distinction appears.| | Under 25 years old | Over 25 years old || Screened or Tested | Yes | 35% | 89% || | No | 65% | 11% | There is a clear indication that those over 25 have attended for STI Testing or Screening (including HIV Antibody) to a larger degree than those under 25 years of age. The figures from GUM for 2008, indicates that 11. 7% of all first time tests are from men whose behaviour is identified as being homosexual in nature. If this is correct then there an indication that a higher percentage of MSM are actually testing than in within the general population.

With regards to specific Chlamydia testing in Quarter 1 and 2 of 2009/10, the total target reached by B&NES PCT was 12% of target. However, if the percentage of under 25 from the assessment are used this appears to indicate that a higher percentage of MSM have been screened for Chlamydia[xviii]. (NHS Vital Signs 2009/10: http://www.

chlamydiascreening. nhs. uk/ps/assets/pdfs/data/VSI_by_PCT_April-December_09. pdf)It is recommended that: ??? Stronger, more targeted information be made available to reinforce the ??? advantages??™ of testing, rather than the ??? disadvantages??™ of not testingQ5. How regularly do you go for a sexual health screening/testing[pic]When looking at the age split it is clear that there is a clear differentiation between the two age groups:| | Under 25 years old | Over 25 years old || Annual Testing | 11% | 37% || Bi-annual Testing | 6% | 10% || Quarterly Testing | 0% | 12% || Between Partners | 15% | 21% || Suspected STI | 68% | 20% || Other Reason | 0% | 0% | There is a significant difference between the two age groups in regards to acceptance for the need to test on a regular basis. On following up, several reasons became clear for the large discrepancy in the groups: Comments by those over 25 ??? I have a regular check up??? (45 year old) ??? As I have so much sex, it makes sense to test, well that what we are always told??? (34 year old) ??? I keep meeting people at the clinic, they??™ve been tested so I know they??™re safe, so I we can have bareback sex, so I guess I go there to pick people up??? (55 year old) ??? Since the AIDS scare I??™ve always gone for a check up every six months, ??? cos that was what I??™ve always been told to??? (49 year old)Comments by those under 25 ??? I only get checked if I think I??™ve got something??? (22 year old) ??? I am fed up with all the Chlamydia stuff, everywhere you go your TOLD to test, why the hell should I, it??™s my choice if I do or not??? (19 year old) ??? I don??™t put myself at risk, I always use a condom??? (19 year old) ??? I can??™t be arsed to get tested, I??™ll get it done if I get something??? (18 year old)From the responses it is clear that those over 25 appear to get a regular check or are more likely to consider a test as they understand it can lead to healthier and better sex. The responses from those under 25, clearly indicates that there a lack of understanding around the need to test, and an almost fatalistic attitude to becoming infected. There also seemed to be to be a strong resilience amongst those under 25 towards testing, which they appear to be attributing to the constant calls from all agencies to undergo testing (Chlamydia), which is leading to an ambivalent attitude due to message burnout.

An example of burnout can be summarised in the comment below: ??? In the last week I have been asked by you, at Uni, in a club, by letter and by my doctor to take a bloody Chlamydia test, how much piss do you think I have in me ??¦??¦??¦ ??? cos I am certainly pissed off with everyone asking, so you can all fuck off ??¦??¦.. and no I am not doing a test for you??? (19 year old)It is recommended that: ??? A different approach, for example broadcast texting, should be adopted for under 25 year olds in B&NES as they are now strongly indicating that testing messages are no longer effective, this is especially true with regards those we have had contact with, with regards to Chlamydia testing. ??? Reliance on National Strategies to target under 25 year olds, may not be the best method to target under 25??™s in B&NES. ??? That stronger, more targeted information be made available to reinforce the ??? advantages??™ of testing, rather than the ??? disadvantages??™ of not testing.

Also there may be a case to ??? incentivise??™ testing, such as offeringQ6. How would you rate your knowledge of Sexually Transmitted Infections1 = No Knowledge5 = Good knowledge10 = Excellent Knowledge| 1 | Q8. Do you know how to access a Hepatitis B vaccine| Yes | No || 43 | 42 | Q9. Have you received the full course Hepatitis B Vaccine| Yes | No | Unaware || 27 | 20 | 38 | Nationally there is now some concern about the lack of knowledge surrounding Hepatitis B, it effects, treatments and vaccinations. This is partly attributed to the need for multiple injections to complete the vaccination, which many MSM seem to have difficulty remembering (despite Vaccination Agencies following up with clients). RUH GUM, admitted that even they have problems getting men to return for second injection and a high percentage fail to return for third injection. They feel that this would be an excellent vaccination that could be easily taken out into the community, especially as this would then allow for a much wider vaccination programme that could easily be available out of normal hours. There is also a need to look at awareness of Hepatitis B amongst the MSM community, and a need to consider adding Hepatitis B to the standard STI Screening, to start to accurately gauge infection rates in the MSM population.

The highest incidence rate for Chronic Hepatitis B is amongst the 25 to 34 age group and that that MSM accounted for 17% of chronic Hepatitis B infections in the UK. Though this doesn??™t indicate the prevalence within B&NES, it can be expected that similar figures will be found in the MSM population in B&NES[xix].| Recommendations: || That investigation takes place within GUM and CaSH to determine the prevalence of Hepatitis B within the B&NES population. || That a highly targeted campaign take place to raise awareness of Hepatitis B and the need for vaccination || That consideration be given to providing a targeted Hepatitis B community based vaccination programme in B&NES (this could also be used || as a co-testing facility for non-invasive STI testing) | Q10. What is your definition of ??? unsafe sex???[pic]With 64% of respondents saying that ??? unsafe sex??? was sex without a condom, this shows a good understanding of the term ??? unsafe sex???, 21% that said unknown partner also supports this.

A further 6% felt ??? unsafe sex??? was being with someone with an STI, this is not overly high and indicates that the message about what is safe sex is getting noticed. ??? Unsafe sex is when I have sex with someone who turns out to have an STI??? (22 year old) ??? Unsafe sex is where you don??™t use a condom??? (45 year old) ??? I think unsafe sex is where you don??™t know the person your with, like if you met them on a night out and took them home??? (19 year old)Upon speaking with these individuals they were unaware that many STI??™s can be symptomless particularly Chlamydia. Recommendations: ??? That the ??? Safe Sex??™ message is working, but should continue from all avenues to reduce the risks of STI and HIV prevalence. Q11. Do you use condoms for: Anal sex| Always | Sometimes | Never || 49% | 18% | 33% | Oral Sex| Always | Sometimes | Never || 4% | 8% | 88% | Condom use within MSM, Gay and Bisexual men is stereotypically felt to be quite low or non-existent, the results show 49% of the individuals always use a condom for anal sex, however 51% either do not use or only sometimes use a condom for anal sex. This figure neither confirms or disproves the current believes. Natsal 2000, indicates that usage does increase with more sexual partners, but even then it ranges from 25% to 43% usage nationally, with a mean figure at 35. 8%.

With 49% IN B&NES indicating usage it appears as usage is above the Natsal average[xx]. However, in the GMSS 2003, it was noted that 59. 6% of gay, bisexual and MSM did not use a condom for either receptive or insertive sexual intercourse. Other research has indicated that 48.

3% of MSM always use a condom, which is in line with these findings, and 38. 8% sometimes use a condom, local results indicate a much lower rate of non usage, thus indicating a better than national average. Of concern is that the same research indicates that nationally only 12. 9% never use a condom, however, in B&NES 33% state they do not use a condom, this figure is nearly three times the national average, so is of concern4. On following up with those that report never to use a condom of anal sex, it was clear that many do not consider themselves at risk for the following reasons, and when factored into the original responses it factually reduces the total down to 11%.

??? I no longer have sex??? n= 3 ??? I am celibate??? n= 2 ??? I do not have or want anal sex??? n= 14This shows that the percentage having unprotected anal sex is actually below the reported national average. We then looked to see if there was any differentiation between ages in comparison with national findings, but it was noted that there was no differential, B&NES follows the national trend at all times, but remains at a slight percentage below the national averages. To further confirm this much deeper analyses was carried out to see if these findings were correct. This was carried out by SIGMA research. It was found that the data collected was robust and that the initial conclusions were correct. However the following points were noted: ??? The numbers in longer term monogamous relationships is not known.

??? The age breakdown showed no increasing non use as age increased. ??? That it appears that within the survey sample there was a better than national average for condom use, but this should be treated with caution, until further research confirms this as it does not fall in line with previous research from Bath (GMSS surveys)In relation to oral sex 96% of respondents do not routinely use a condom. Though outwardly this appears a high percentage this is very much in line with all other surveys carried out in the UK. What is not known here is how many are in longer term monogamous relationships; this would have a bearing on the overall findings. Recommendations: ??? That the percentage use of condoms for anal sex be further investigated as this does not follow national or comparable regional known trends. ??? That further and consistent health promotion be targeted at the advantages of using condoms, such as well advertised web information and targeted leaflets, which are aimed at each age range. Q12.

Where do you get your condoms from[pic]It can be seen that the largest majority get their condoms from ??? other??™ routes, on following up with participants they indicated that they obtained them from Gay Bars, Male Saunas or the various Gay Clubs in Bristol, where condoms are provided free. The second largest grouping then moves onto the purchased condom, through either retail outlets or Pharmacies. The lowest group was uptake from PCT Sexual Health Services (GUM, CaSH and GPs)The final result that came to light was that in the Survey 36% identified as being university students, yet only 7% indicated that they obtain condoms from the Universities, on further investigation it was found that the remainder obtain them from ??? other??™ free sources, such as the gay venues, and the student population indicated that due to severe financial constraints they would always target ??? free??™ condoms, thus ensuring that they have them when needed. We also looked at the age split; however, there was no significance between the age groups in methodology of obtaining condoms. Q13. What would make you more likely to use a condom[pic]Q14.

What would make it more likely for you to have unprotected sex[pic]When comparing the above two responses, it is clear that there are some strong commonalities in responses. 38% stated that they would cease to use a condom when with a regular partner, and 40% stated that they would be more likely to use a condom when with a new partner. It is noted that Alcohol has a very large effect on when people would not use a condom with 41% stating that they would probably not use. Conversely, only 2% would use due to alcohol usage. When compared with GMSS 2003, 2005 and 2007, both sets are consistent with both regional and national findings; however, it has been noted that between 2003 and 2007 GMSS Surveys the regional and national percentages of those not using a condom had in itself risen by 15%.

??? When I??™m pissed I always forget to use, unless the person I am with asks me to use one [Condom]??? (19 year old) ??? When I have sex it??™s as safe as I want it to be, irrespective of if I??™ve been drinking or not??? (45 year old) ??? Sometimes I am asked to Bareback, it sometimes worries me, but when you have had a few drinks who really cares??? (22 year old)It is seen that only 6% of respondents are saying that they are not using due to not having access to condoms, which though not specifically asked indicates that 94% had access to condoms, which in comparison to some other areas (Sheffield 2009) the availability in B&NES is higher by 23%. This can be attributed to the availability of Condoms in Venues in both Bath and Bristol. Of interest is that 5% of respondents are openly stating that drugs can result in probable none use of condoms, but we are unable to compare this directly with other areas or GMSS surveys as these have combined alcohol and drugs under one heading. It is recommended that the provision of free condoms and lube continue in the venues: ??? To ensure that at a high percentage of gay, bisexual and MSM have access to condoms and lube, by ensuring a supply is available at all LGB&T venues and are available by post.

??? Where applicable it would alos be strongly advisable to ensure outreach work is carried out into PSE area (Junction 18 and Tog Hill) to ensure there is a provision of condoms at these locations. Q15. Where would you go to meet men for sex and/or a relationship[pic]Ten years ago this question would have elicited very different responses, as at that time there was very little use of the internet and much higher use of PSE??™s. Indeed over the past 10 years there has been a marked transition from direct PSE usage to use of the internet, and other surveys and organisations have noticed an almost like for like move from PSE to Internet. Studies indicate that it is almost an identical percentage change in the two areas. From this study it can be seen that 16. 4% of MSM still use PSE sites that are associated with B&NES, but these tend to be either Tog Hill or Junction 18, which has been confirmed from discussions with some of the MSM who answered this question.

However, when looking at age splits it was clearly noted that a significant number 78% of those using PSEs were aged over 45, and these men readily admit they do not like the ageism of the internet. We also noted the high numbers that stated they meet via ??? other??™ means (30. 9%), and on following this up with those that indicated a willingness to re contacted this broke down as follows: Met through friends11%Initial contact via internet, followed up at public location*36%Opportunistic meeting (non-commercial venues)*49%Student accommodation 4% *Following the response in regards to opportunistic meeting, further follow up was carried out to identify what MSM were defining as public location or non-commercial venues. When speaking with these men, it quickly became clear that they were identifying with PSE, but not associating the location as a PSE, such as toilets in a supermarket, meeting someone on the way home from a club or pub, or even meeting a train or bus. On each occasion they clearly indicated that this was stranger contact. It was clear from these discussions that though PSE in nature the MSM??™s concerned didn??™t associate these as PSE locations, as the locations were opportunistic in nature, rather than fixed traditional locations.

It was again noted that by far the majority of those stating other (62%) were over the age of 45. We then looked for comparisons in other areas, but it was found that nationally this was a localised response and all areas show widely differing numbers. The only commonality is that the numbers using the internet are increasing and the numbers using the PSE are decreasing. Q16. Where would you feel is the best place to advertise sexual health services and campaigns where you would take notice[pic]This question was asked with the intent to determine the type of locations that the respondents felt would have effect in health promotion messages, and would be of value in assessing the best locations for targeted work. There were several areas that respondents felt should be targeted such as Clubs/Bars 48 respondents felt these were good locations, a further 23 felt advertising in toilets would be advantageous and 21 felt advertising in Universities and on public transport would be effective. Of interest was that only 9 felt that specific advertising in magazines and such publication would have an effect, which traditionally has been the main route for many organisations.

In 2001 (How to be a Homosexual) discussion took place as to the effectiveness of small media health promotion, and it was concluded that there was a shift from targeted messages to normative messages contained in Health Promotion, and drew the conclusion that there is now les of a need for specific targeted information. However, this has always resulted in differing responses in different areas. CHAPS, THT and SIGMA have now opted for small media and direct working, whereas organisations such as Eddystone Trust and MESMAC prefer using Pubs/Club and magazines. It is recommended that: ??? Further information and education around the range of available services within B&NES is targeted in a proactive manner aimed at the MSM population. Q17. What sexual health services would you like to see/feel isn??™t being provided in the Bath and North East Somerset area[pic](n= 129 responses)Q18.

What improvements would you like to see made to existing sexual health services in Bath and North East Somerset that would make you more likely to access them[pic](n= 119 Responses)These questions were designed to investigate what services the gay, bisexual and MSM community felt were ??? missing??™ or needed improvement within B&NES, and to further identify if there is sufficient need for a new service or type of service provision to the community. The largest area of concern is that it was indicated that there needed to be an improvement to Access to Services within B&NES (40. 3%) and when following up it became very clear that there were major concerns about the restricted opening times of the GUM clinic at RUH. ??? I work 9 to 5, the clinic works 9 ??“ 5, how the hell am I supposed to get there, and this is why I go to Bristol, and until they [RUH] change their opening times they are certainly not there for us ??¦..

It??™s almost as if they are forcing us to go elsewhere because they don??™t want us going there??? (35 year)It can be seen that the MSM community are also strongly suggesting that as a solution Community Testing should be increased which they felt would allow for this restriction on opening to be addressed. We are also aware that there is Community Testing in some other areas of the UK, and some of these responses could be driven by ??? If they have it we want it??™, but what is not clear from following up is how well community testing would be utilised. ??? I wish we could have a out of hours testing service, that way more people could actually get to it locally rather than travelling to other clinics ??¦. I would use it when I thought I had an STD, as I always go out of area for HIV testing, in case I am seen??? (22 year) ??? If there was community screening available, I don??™t think we would use it as to many people who we see everyday would see us using it, I will still go to Bristol??? (35 year)There was a small number (7. 5%) who felt that Rapid HIV testing would be beneficial, however, from previous qualitative responses from those surveyed, it is felt that this service would not be used by the local community, but could potentially be used by those travelling from out of area, as many of the B&NES community already do. It is recommended that: ??? The opening times of the RUH GUM Clinic be reviewed, and if these times cannot be adjusted that, further investigation take place to look at the viability and cost effectiveness of some form of community based service. ??? That further advertising of the Riverside service take place.

Q19. In what other ways would you like to access sexual health information[pic]As peoples access to IT, the internet and wide area communication improves it is clear from the above results that the majority are using ??? modern??™ methodologies to access information . 62% of respondents indicated that they sought information from the internet or from facebook, with a further 17% ind

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