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Sexual Health

Introduction

Sexual health is defined by the World Health Organisation as "a state of physical, emotional, mental and social wellbeing in relation to sexuality; it is not merely the absence of disease or infirmity". Sexual health requires "a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For positive sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled".

Responsibility for commissioning sexual health services transferred from the NHS to local authorities in April 2013. Some specialised services are directly commissioned by Clinical Commissioning Groups (CCGs) and at the national level by NHS England; for example commissioning of HIV treatment services and termination of pregnancy services.

Commissioning by local authorities should encompass open access Sexual Health services for everyone present in the locality, whether resident or not. This includes:

  • free STI testing/ treatment,
  • partner notification
  • free contraception and reasonable access to all methods of contraception
  • specialist sexual health services related to prevention and health promotion in various settings.

Sexually transmitted infections (STIs) are infections that are transmittable from one person, to another through unprotected sex or genital contact. The most common STI in the UK is Chlamydia, other STIs include syphilis, gonorrhoea, genital warts, genital herpes, trichomoniasis and pubic lice. Many people can have an STI without showing any symptoms and therefore do not know they have an infection; which could unknowingly be passed on to sexual partners through unsafe sex. STIs can be detected from a urine sample, swab or blood test and most can be treated using antimicrobials, with the exception of viral STIs. Surveillance of STIs diagnosed in sexual and reproductive health (SRH) and genito-urinary medicine (GUM) services is undertaken by Public Health England (PHE).

Hepatitis B and C can be transmitted through unprotected sex and are covered in the Communicable Diseases section of the JSNA.

The primary risks of sexually transmitted infections is their propensity to be spread easily and amongst many people (the number of people infected increases year-on-year), leading to a variety of different health problems requiring treatment, including the substantial cost of HIV treatment. 'Unprotected' sex can not only lead to infections but also to unplanned pregnancy.

What do we know?

Sexually transmitted infections: Public Health England's (2015) Health Protection Report on sexually transmitted infections (STIs) and chlamydia screening reports that diagnoses of chlamydia, gonorrhoea, syphilis, genital warts and genital herpes have increased considerably in England over the last 10 years. The most notable increase is amongst males, although some of this increase can be explained by the introduction of more sensitive testing methods. Ongoing unsafe sex also continues to play an important role in this increase. In 2014, there were approximately 440,000 new STI diagnoses made in England. The largest increases between 2013 and 2014 were for syphilis (33%) and gonorrhoea (19%), with sharper increases of these infections (46% for syphilis and 32% for gonorrhoea) among men who have sex with men (MSM).

A small number of STIs can be fatal, such as hepatitis B, hepatitis C and syphilis. Others can lead to chronic infection, pain and to other consequences such as infertility. Many produce unpleasant symptoms. Unlike infections such as measles and whooping cough, individuals do not develop immunity to the organisms that cause STIs, therefore many can be recurrent, particularly in those who repeatedly undertake 'risky' sexual behaviour. High levels of gonorrhoea transmission are concerning because strains of the infection that are resistant to commonly used antimicrobials have been reported in the UK.

Chlamydia is the most common bacterial sexually transmitted infection, with sexually active young people at highest risk. Chlamydia often has no symptoms and if untreated can result in pelvic inflammatory disease and fertility problems.

HIV: HIV (Human Immune Deficiency Virus) is also transmitted through unprotected sex, as well as via the blood through practices such as sharing needles if injecting drugs or other substances. The HIV virus attacks and weakens the immune system, making it less able to fight infections and disease.

Public Health England's HIV in the UK - Situation Report 2015 estimated that 103,700 people were living with HIV (PLWH) in the UK. Approximately 67% of these were men and 33% were women. This compares to an estimated 100,000 PLWH in 2013. Public Health England also reports that a total of 6,151 people were newly diagnosed with HIV in the UK during 2014, of which 75% were men and 25% were women. 3,360 (55%) of new diagnoses were in men who have sex with men (MSM) and 1,044 (17%) in Black African men and women. Around 17% of PLWH are unaware of their infection, which is a decrease from 25% in 2010, and they are therefore accessing the treatment they need. These people are also at risk of unknowingly passing on HIV if they have sex without a condom.

The lifetime costs of treating a person with HIV are between £280,000 and £360,000 (HPA,

2012) depending on whether the condition is diagnosed early or late. The average age at which patients are diagnosed is in the age band 25-34 although HIV can be transmitted at birth. Where newly diagnosed patients are diagnosed late then the average annual expenditure is double that of a patient diagnosed early. The average cost of treating a patient with HIV is £13,900 per annum; however, if patients are diagnosed late this can increase inpatient care costs 15 fold. Late HIV diagnosis remains a problem in the UK and is the most important predictor of HIV-related illness and short-term death. People diagnosed with HIV late have a ten-fold increased risk of death in the year following diagnosis when compared to those diagnosed early. In 2014, two out of five people newly diagnosed with HIV were diagnosed at a late stage of infection. Most people with HIV look and feel healthy and do not experience any symptoms. People can live with HIV and expect a near normal lifespan if they are given the right treatment and care. HIV can be detected with a simple blood test. Early diagnosis and treatment in the UK is successful with 95% of all people on anti-retroviral treatment demonstrating suppression of the HIV virus. In 2013, two thirds of all PHWH were estimated to have an undetectable viral load (Public Health England, 2014, HIV in the United Kingdom: 2014 Report).

Teenage Pregnancy: Teenage pregnancy and early motherhood can be associated with poor educational achievement, poor physical and mental health, social isolation, poverty and other related factors. Teenage mothers are less likely to finish their education, are more likely to bring up their child alone and in poverty and have a higher risk of poor mental health than older mothers. Infant mortality rates for babies born to teenage mothers are around 60% higher than for babies born to older mothers. Around half of teenage pregnancies in England and Wales end in abortion (Public Health Outcomes Framework). Although teenage pregnancy rates have fallen nationally England still has one of the highest rates in Europe (NICE 2014). Improving contraceptive services and advice given to young people is crucial in helping to reduce the number of unplanned pregnancies. NICE recommends that commissioners ensure that all young people can easily access contraceptive services that provide empowering information and advice about sex and relationships regardless of place of residence.

Over the last decade, the numbers of young women becoming pregnant before the age of 18 reduced substantially in England and Wales. In 1998, there were 46.6 terminations per 100,000 women aged 15-17, compared to 24.3 in 2013 (Public Health Outcomes Framework).

Contraception: is widely available in the UK from a number of sources. Contraception is available free of charge from General Practices, sexual and reproductive health services, young person's clinics and NHS 'walk-in centres (emergency contraception only).

Contraception can be divided into two main groups:

  • user dependent methods - these require the person to remember to take or use them (male and female condoms, diaphragm and female contraceptive pills)
  • long-acting reversible contraception (LARC) methods - these have to be fitted by a professional and can last for a number of years (intrauterine devices, implants or injections).

LARC methods are considered to be more cost effective than user dependent methods and their increased uptake could further help to reduce unintended pregnancy (National Institute for Health and Care Excellence Clinical GuidelinesCG30), although they do not protect from STI transmission. All currently available LARC methods have been shown to be more cost effective than the combined oral contraceptive pill even at 1year of use.

The most common method of contraception prescribed through SRH services is the oral contraceptive pill. However, over the last ten years the proportion of women using long acting reversible contraception (LARC) as their main contraceptive method has been increasing and the proportion choosing user dependent methods has been decreasing.

Emergency contraception ('the morning after pill') is available for free from GPs, sexual and reproductive health clinics and some pharmacists. This can also be bought over the counter at some pharmacies and private clinics. Some LARC methods can also be used as emergency contraception.

The Health & Social Care Information Centre's (2015) Sexual and Reproductive Health Services for England reports that over 2 million contacts with Sexual and Reproductive Health services were made by more than 1.3 million people between April 2014 and March 2015. 90% of attendances were made by women, which represents 8% of all females aged 13 to 45. Women aged 18 to 19 were most likely to use a service, where 21% of women in this age group had at least one contact in 2014/15.

Figure 1: Main method of contraception for women in contact with Sexual and Reproductive Health service, England (2004/05 to 2014/15)

image1

Source: Health & Social Care Information Centre (2015); Sexual and Reproductive Health Services for England

The number of Emergency Hormonal Contraception (EHC) items provided to women by SRH services and other locations in the community has fallen by 39% over the last ten years from around 521,000 in 2004-05 to 318,000 in 2014-15. This does not represent the total amount of EHC, as since 2001 this has been purchasable over the counter at a pharmacy without the need for prescription and can also be prescribed by nurses and pharmacists.

Termination of pregnancy: The earlier abortions are performed the lower the risk of complications. Prompt access to abortion, enabling provision earlier in pregnancy, is also cost-effective and an indicator of service quality and increases choices around procedure.

The abortion rate in women aged 15 to 44 increased in the 1970s before beginning to fall in the early 2000's. The abortion rate per 1,000 resident women aged 15-44 in England was 15.9 in 2014, which was the lowest rate since 1997 (Department of Health, 2015, Abortion Statistics: England and Wales, 2014). The National Survey of Sexual Attitudes and Lifestyles (2010-12) found that 16.2% of pregnancies in the year before the study interview were unplanned. This survey found that:

  • Pregnancies among 16 to 19 year olds accounted for 7.5% of the total number of pregnancies, but 21.2% of the total number that were unplanned.
  • The highest numbers of unplanned pregnancies occur in the 20 to 34 year age group. Unplanned pregnancies can end in abortion or a maternity. Many unplanned pregnancies that continue will become wanted. However, unplanned pregnancy can cause financial, housing and relationship pressures and have impacts on existing children. Restricting access to contraceptive provision by age can therefore be counterproductive and ultimately increase costs.

Still births: A still birth is defined as a baby born at 24 or more weeks completed gestation that did not breathe or show signs of life at any time. The causes of many stillbirths remain unknown, but may include maternal infections in pregnancy, maternal disorders (especially hypertension and diabetes) or congenital abnormalities. More information is included in the Infant Mortality section of this JSNA.

Facts, Figures, Trends

Reading in 2014:

  • 1,898 acute sexually transmitted infections (STIs) were diagnosed in Reading residents.
  • A rate of 1191.9 new STIs per 100,000 residents was recorded, this is higher than the England rate of 797.2 per 100,000 and an increase of 7.5% compared to 2013
  • The rate of new STI diagnoses, excluding chlamydia diagnoses in those aged under 25, was 1,094 per 100,000 in Reading. This is higher than the England rate of 829 per 100,000 and also higher than the rate in the fifth less deprived comparator group of local authorities (815 per 100,000).

Figure 2: Rate of new STI diagnoses (excluding Chlamydia in under 25 year olds)

image2

Source: Public Health England Sexual Health Profiles

  • In 2014, Reading had the 31st highest rate of new STI diagnoses in England. Reading's rates have remained higher than the England rate over the past three years.
  • 49% of diagnoses of acute STIs were in young people aged 15-24 years, compared to 46% in England.
  • In Reading, for cases in men where sexual orientation was known (n=135), 16.1% of new STIs were among men who have sex with men (gay & bisexual men)
  • There was an increase in the rates of Syphilis detected in Reading late in 2014, mainly in men who have sex with men (MSM).

Gonorrhoea:

Source: Public Health England Sexual Health Profiles

  • In 2014, Reading's diagnosis rate of gonorrhoea was significantly worse than the England and comparator group rates at 127 per 100,000 15 to 65 year olds. This is a marker of high levels of risky sexual activity.
  • Rates of gonorrhoea diagnosis have increased nationally over the past four years.
  • While Reading had a decrease between 2010 and 2012, there was a notable increase in 2014. Reading also saw an increased incidence of syphilis in 2014, in line with the national trend.

Figure 3 shows the rate of specific STIs in Reading - 49% of diagnoses of acute STIs were in young people aged 15-24 years, compared to 46% in England.

Figure 3: Rate of specific STIs in Reading (2010-2014)

Indicator

2010

2011

2012

2013

2014

Syphilis diagnosis rate per 100,000 15-65 year olds

7

7

7

2

11

Gonorrohea diagnosis rate per 100,000 15-65 year olds

122

95

79

84

127

Chlamydia detection rate per 100,000 15-24 year olds

  

866

695

680

Source: Public Health England Sexual Health Profiles

HIV:

  • The HIV prevalence rate in Reading was 3.1 per 1,000 population aged 15-59 in 2014 (321 people living with diagnosed HIV); this is significantly higher than the national rate of 2.2 in England (n=346) and 2.0 in the comparator group.
  • The rate of new HIV diagnosis was also significantly higher in Reading at 17.0 per 100,000 people aged 15 and over, compared to 12.3 in England and 8.1 in the comparator group.
  • The rates of diagnosed HIV and new HIV diagnoses have remained fairly stable over the last four years in Reading, although consistently higher than the national rates (Public Health England Sexual Health Profiles).
  • HIV prevalence varies widely nationally but is often higher in urban areas.
  • 52% of people living with HIV in Reading are Black African and 31.9% are white
  • 70.4% of HIV infections were likely to have been acquired through heterosexual sex and 22.5% through sex between men
  • Late HIV diagnosis is the most important predictor of HIV-related illness and short-term death. Between 2012 and 2014 48.5% of HIV diagnoses were made at a late stage of infection compared with 42.2% nationally and 44.4% in the comparator group. Although late diagnosis rates are higher in Reading than regionally and nationally, the difference is not statistically significant.
  • 26.3% of men who have sex with men (MSM) and 60.5% of heterosexuals were diagnosed late. (Public Health England, 2015: Reading Local Authority HIV, sexual and reproductive health epidemiology report).

HIV testing:

In 2014, an HIV test was offered at 60.9% of eligible attendances at GUM clinics by residents of Reading and where offered, an HIV test was carried out at 81.8% of these attendances. Nationally, an HIV test was offered at 80.1% of eligible attendances at GUM clinics with an uptake at 77.5% of these attendances (Public Health England, 2015: Reading Local Authority HIV, Sexual and Reproductive Health Epidemiology Report).

Contraception:

In 2014, 1,740 women were prescribed LARC through a GP in Reading. This was a rate of 45.7 per 1,000 women aged 15 to 44, which was significantly higher than the England rate of 32.3 per 1,000 women. The rate of LARC prescribed in Sexual Reproductive Health services per 1,000 women aged 15 to 44 years was 17.4 for Reading, which was lower than the England rate of 31.5. (Public Health England, 2015: Reading Local Authority HIV, Sexual and Reproductive Health Epidemiology Report).

355 women resident in Reading were prescribed emergency contraception at Sexual Reproductive Health services in 2014. Of those, 8.9% were prescribed it more than once, compared to 10.0% in England.

The number and type of contraception provided in Sexual Reproductive Health Services and general practice in Reading is shown in figure 4.

Figure 4: Number and type of contraception provided in SRH services and general practice in Reading 2014

image3

Source: Public Health England (2015); Reading Local Authority HIV, Sexual and Reproductive Health Epidemiology Report

Teenage pregnancy in Reading:

Reading had 56 conceptions to under 18 year olds in 2014. This was a rate of 23.1 per 1,000 females aged 15-17 and was similar to the England rate of 24.3 per 1,000. Between 1998 and 2013, the number of under 18 conceptions reduced in Reading by 63%, compared to a 48% reduction national (Public Health Outcomes Framework). Additional information can be found in the Teenage Pregnancy section of this JSNA.

Termination of pregnancy:

  • The total number of abortions in Reading in 2014 was 756 an increase of 0.53%
  • The total abortion rate per 1,000 female population aged 15-44 years was 19.8, and was significantly higher than the England rate of 16.5 (rank 37 of 146 local authorities).
  • The proportion of under-18 conceptions leading to abortion in Reading was 53.6% in 2014. This was similar to the England proportion of 51.1%.
  • In 2014. 84.3% of NHS-funded abortions were performed under 10 weeks gestation in Reading. This was significantly better than the England rate of 80.4%.
  • The proportion of women aged less than 25 who had a repeat abortion was 33% in Reading, which was significantly higher than the England figure of 27%. Among women aged 25 and above, 49% had had a previous abortion, compared to 46% in England (Public Health England, 2015: Reading Local Authority HIV, Sexual and Reproductive Health Epidemiology Report).

The earlier abortions are performed the lower the risk of complications. Prompt access to abortion and enabling provision earlier in pregnancy is also cost-effective and an indicator of service quality.

Service use:

In 2014 there were 9,491 first attendances at sexual health (GUM) clinics by residents of Reading. 95% of these attendances were at the Royal Berkshire Hospital (Public Health England, GUMCAD). Figure 5 shows that 53% of these attendances were for women and 62% were for people aged 20 to 34. 70% of attendances from people with a recorded ethnicity were from a White ethnic background.

Figure 6: Number of first attendances at GUM clinics for residents of Reading by gender, age and ethnicity (2014)

Age groupMaleFemale
Under 15<520
1510-1537
16 to 19408758
20 to 2410641649
25 to 3415811559
35 to 44766657
45 to 64572341
65 +4126
Total44445047

 

EthnicityNumber
White6625
Black or Black British1557
Asian or Asian British424
Mixed584
Other ethnic group163
Not stated138

Source: Public Health England, Genitourinary Medicine Clinic Activity Dataset report generated from the PHE HIV and STI Web Portal.

In 2014, there were 3,127 attendances to Sexual and Reproductive Health Services from Reading residents. 94.1% of these attendances were at services in Berkshire and 87.6% were to the Royal Berkshire Hospital Sexual Health Department. Regular contraception was prescribed at 2,835 of these attendances (rounded to the nearest 5).

The largest proportion of attendees was aged 20 to 24 (41.7%). Male attendees made up 5.1% of attendances, compared to 11.2% nationally (Public Health England, 2015: Reading Local Authority HIV, sexual and reproductive health epidemiology report).

National & Local Strategies (Current best practices)

There are number of national and local strategies to control and prevent STIs and to outline best practice on aspects of sexual and reproductive health. These include:

Strategies

Standards

National Institute for Health and Care Excellence (NICE)

What is this telling us?

Sexual ill health is a significant issue in Reading. Incidence of STIs and the HIV diagnosed prevalence rates were both significantly higher than the England rate and the comparator group average.

The rates of STIs in Reading are generally above the England average and the number of diagnoses is increasing. This may be due to:

  1. Better and increased uptake of screening.
  2. An increase in risky sexual behaviour.
  3. An increase in the number of people using sexual health services in Reading, both local residents and those coming to Reading for out of area treatment. The latter may be visiting the area due to the social opportunities, wanting to maintain anonymity by seeking advice outside of their home town / place of work and / or the provision of reputable sexual health services.

Early diagnosis and treatment of HIV can reduce health and social care costs, and there are close relationships between substance misuse, including excess alcohol consumption, and both sexually transmitted infection spread and unplanned pregnancy.

  • Two groups at particularly high risk of STIs including HIV in Reading appear to be MSM and the Black African community.
  • It is widely reported that STIs occur more commonly in people who live in more deprived areas. This is important to consider when targeting prevention services.
  • Younger people are more likely to be re-infected with STIs; therefore education and development of condom negotiation skills is key as part of health promotion and condom distribution schemes.

The new service specification for GUM services commissioned from April 2015 includes a specific focus of engaging with people in the community at increased risk of STIs, HIV and unplanned pregnancy. However, we also need to ensure that community services and other organisations are well integrated with referral routes and are able to provide consistent, acceptable support and advice on sexual health and relationships for service users.

The majority of Reading residents who use sexual health services access these within Berkshire. In 2014, 88% of Sexual and Reproductive Health Service attendances and 95% of first GUM attendances for Reading residents were at the Royal Berkshire Hospital.

Conceptions and terminations.

The rate of teenage conceptions in Reading has reduced over recent years and was similar to the England rate in 2013. However, this was significantly better (lower) than the comparator group average.

What are the key inequalities?

Age:

STI diagnosis rates in England are highest in young people aged 15-24 years of age. 49% of diagnoses of acute STIs among Reading residents were in this age group, compared to 46% in England (Public Health England, 2015: Reading Local Authority HIV, Sexual and Reproductive Health Epidemiology Report).

However, whilst many prevention/sexual health promotion services are targeted at young people, a considerable proportion of people who get STIs are in older age groups and we need to ensure that prevention work, health promotion and GUM services are equitable for all age groups

Sexual Orientation:

Nationally, the number of STI diagnoses in MSM has risen sharply. In Reading, for cases where sexual orientation was known, 16.1% of new STIs were among men who have sex with men (gay & bisexual men).

The national HIV prevalence rate in 2012 was 1.5 per 1000 of the population. Men who have sex with men nationally have the highest rate at 47 per 1000 living with the infection.

HIV is predominantly now transmitted through heterosexual contact, although rates remain highest nationally amongst men who have sex with men and Black African communities (PHE/HPA, 2013). For HIV, the majority (70.4%) of new HIV infections in Reading were likely acquired through heterosexual sex and 22.5% through sex between men.

Ethnicity:

The 2013 Berkshire Sexual Health needs assessment shows that compared to national reports, HIV rates of transmission are greatest among sub-Saharan African and other black Caribbean groups, which form a higher percentage of the population in Reading. 52% of people living with HIV in Reading are Black African and 31.9% are white. (Public Health England, 2015: Reading Local Authority HIV, Sexual and Reproductive Health Epidemiology Report).

Socio-economic deprivation:

Socio-economic deprivation is a well-recognised determinant of poor health outcomes and data from GUM clinics show a strong positive correlation between rates of new STIs and the index of multiple deprivation across England. The relationship between STIs and socio-economic deprivation is probably influenced by a range of factors such as the provision of and access to health services, education, health promotion, the likelihood of seeking health-care and sexual behaviours. ((Department for Education and Skills, 2006).

Socio-economic disadvantage is also recognised as both a cause and a consequence of teenage motherhood with children of teenage mothers having an increased risk of living in poverty and poor quality housing and at higher risk of accidents and behavioural problems (Department for Education and Skills, 2006).

Rates of new STIs in Reading were lowest in the Borough's least deprived quintile (374 per 100,000 population) and highest in the 4th least deprived quintile (1,170 per 100,000). Rates in the most deprived quintile were slightly lower at 1,051 per 100,000 (Public Health England, 2015: Reading Local Authority HIV, sexual and reproductive health epidemiology report).

In England, there is a strong correlation between deprivation and conception rate, with the most deprived areas having the highest rates of conception. Reading has a higher under-18 conception rate than average for its level of deprivation.

What are the unmet needs / service gaps?

A sexual health needs assessment for Berkshire was undertaken in 2013, which identified unmet needs and gaps across the county.

The commissioning of a new GUM service in Reading in 2015 provided the opportunity to acknowledge many of the gaps identified in the needs assessment and ensure that the service now works towards tackling these inequalities. For example, the employment of specialist sexual health outreach nurses to reach vulnerable groups and increased clinic provision, including weekends. Continued service development and monitoring will help us to ascertain the effectiveness of the new service in tackling STIs in Reading.

A new information technology platform has been commissioned across Berkshire to create a single website for all sexual health service information across the county. The website will be widely accessible on both computers and smartphones and aims to help empower residents to take care of their own sexual health through clinic booking, live updates on opening times, information and a clinic locator tool.

A review of Local Authority commissioned condom distribution services has been recommended for 2016 in order to ensure effective provision for young people and high risk groups, along with educational and advisory elements relating to sexual health and relationships. These services will form a key element of our efforts to reduce the prevalence and incidence of STIs, including HIV in the borough.

Recommendations for consideration by other key organisations such as: CCG's, General Practices, Local Authority departments and other providers.

The detection and treatment of all sexually transmitted diseases through screening of symptomatic patients in is an important function of a sexual health service. However, by placing a stronger emphasis on prevention of all STIs and unwanted pregnancy through the provision of condoms (including education on condom negotiation skills, correct and consistent use), sexual health advice and partner notification we can reduce the overall incidence, prevent the spread of infection and the occurrence of unwanted pregnancy.

Reading's HIV rates exceed 2 per 1,000 population aged 15-59, which is the threshold where expanded HIV testing is recommended (British HIV Association, 2008) For patients diagnosed with HIV, prognosis is greatly improved if the condition is detected and treated early. The Berkshire sexual health needs assessment 2013 recommends that a range of communication methods are used for raising awareness of HIV, including; education and awareness-raising, community awareness, web/internet, social media and flyers in the persons first language. There is also an identified need to reduce the stigma of testing and positive diagnosis.

Unplanned pregnancy: As 28% of abortions in under 25 year olds in Berkshire are in women who have previously had an abortion, it is important to ensure closer integration of termination services, sexual health promotion and contraception provision.

This section links to the following sections in the JSNA:

Teenage pregnancy rates

Infant Mortality

Antenatal & Newborn Screening

Liver Disease

Communicable Diseases

Child Sexual Exploitation

Female Genital Mutilation (FGM)

Lesbian, Gay, Bisexual, & Trans (LGBT) People

Drugs & Alcohol

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