Download Inequities in Sexual Health Services: Analyzing Coalfields' Structures, Processes, and Use and more Study notes Public Health in PDF only on Docsity!
Project: Sexual and Reproductive Health services Profile Title: Sexual Health Author/Priority Lead: Chris Allan Date of Submission: 30 th^ March 2018 Document Reference no:^ [insert reference no^ here] Version no:^ 1 Please ensure you complete the version control to ensure the most recent document is presented. Version Comments Author Date Issued Status Draft Version 1 Sections to be updated include service review and results from public survey Chris Allan 19/01/2018 Draft for review Draft Version 2 Includes summary of findings from previous engagement exercises Chris Allan 31/01/2018 Draft for review Draft Version 3 Proof reading and quality assurance Lorraine Hughes 23/2/18 Chlamydia data to be included Final Version Chlamydia data included Lorraine Hughes 30/3/18 Awaiting update of stakeholder engagement when completed. Final Version Sexual and Reproductive Health Profile Updated following national data release on 5th June 2018. Inclusion of syphilis data from 2016 LASER report. Lorrain Hughes 7/6/ Final Version Stakeholder engagement section updated Nicola Cummings 8/6/18 To be published Final Version Sunderland Local Authority HIV, Sexual and reproductive health epidemiology report (LASER) 2017 released on the 7 th January 2019. Nicola Cummings 7/01/ Final Version Quarter 3 STI information included Nicola Cummings 27/03/
This should be read in conjunction with: Teenage Pregnancy Strategy and Action Plan Executive Summary Demography The local population is predicted to grow over the next 20 years, with the largest increase being in those aged 65 and above. This will place greater demands on the working-age population, including fertile women (aged 15-44). Total fertility rates in England have fallen below a level at which the population can reproduce itself through childbirth alone. This is due to a range of factors including socioeconomic factors, increasing proportions of women delaying fertility and choosing not to have children. Sunderland has one of the lowest total fertility rates within the North East of England. In 2015 this was 1.62 births per female aged 15-44, against a regional average of 1.71 and an England average of 1.82. Increases in conception rates are strongly associated with increases in area-level deprivation. This is also the case for under-18 conceptions. The introduction of a two-child limit for Child Tax Credit, Housing Benefit and Universal Credit from 6 April 2017 may lead to a reduction in conception rates for people in groups who would previously have been eligible, and Brexit may affect inward migration for the population as a whole. These combined factors may require positive and context-sensitive sexual health promotion in the local area, with a focus on the areas of greatest need. Sexual health and behaviours Young people and men who have sex with men (MSM) are amongst the groups most at risk of being diagnosed with a Sexually Transmitted Infection (STI). In 201 7 , 58 % of diagnoses of new STIs in Sunderland were in young people aged 15-24 years although people aged 15-24 represent 12% of the local population. Of new STIs in Sunderland in 201 7 12.9% were among gay, bisexual and other men who have sex with men, although the prevalence of men having a male partner may be as low as 3%. Analysis of local service activity data suggests that gay mean accessing HIV-related care are amongst the most frequent users. In England the age at first heterosexual intercourse has declined to an average of 16 years amongst 16- 24 year olds, with about 3 in 10 people reporting having first sex before the average age of 16. This supports offering sexual health education and information and contraception to younger people. The forthcoming changes to Relationships and Sex Education (RSE) offer an
There is some evidence of good interfaces between the commissioned services and those who serve vulnerable groups, although this is not consistent. Capacity building, improved networking and outreach could help to fill perceived shortfalls. Services are accessed mostly by younger people, who are expected to be in the greatest need. 97% of CaSH and 52% of Genitourinary Medicine (GUM) service users were female. This raises the question of whether the STI prevention element of CaSH has been effective, and shows in service activity the effect of some young women opting to use the CaSH services rather than GUM. An integrated, universal, open and accessible service could address such anomalies. 59.9% of C-Card service users were male with the highest usage seen in 14-year-olds. Qualitative work suggests there may have been some wastage, and that the data burden of the scheme was considered to be too costly, which impacted on access and opportunity costs. The Chlamydia detection rate has been declining since 2013, although positivity remains high particularly amongst males aged 20-24 years. This indicates the need to increase throughput for chlamydia screening whilst continuing to target those most at risk. Broader approaches to increasing throughput may reduce overall positivity, but would still improve the detection rate. New Gonorrhoea infections were more likely to be experienced by younger women and older men, possibly indicating a greater need for STI prevention work with younger women and men outside of the eligible age for C-Card. Data from Public Health England suggests that Sunderland has a high rate of late HIV diagnoses which, given the low numbers involved, may present an opportunity for further investigation (deep dive). People from BAME backgrounds appeared to be well served by local SRH services. Whilst access to C-Card reflected a strong relationship with deprivation, this was not the case for access to CaSH or GUM on the whole, although further analysis of service activity data may show correlations with particular interventions or conditions (such as gonorrhoea diagnoses noted above). Data suggests residents of the Millfield ward may be underserved by the C- Card scheme although proportional lack of take-up may have been affected by a relatively affluent local student population. On the other hand, residents of Millfield disproportionately accessed the GUM service, which may be reflective of the location of the sexual health services. Residents of Washington locality may have been underserved by C- Card and GUM services, but take-up might have been affected by the relative affluence or lower deprivation faced by residents in the area. Residents of the Coalfields may be underserved by CaSH and GUM services, representing around 12% of service users but 17% of the local population.
Given the variation in access by location, commissioners should consider how underserved populations and groups can be equitably addressed through positive health promotion, dedicated outreach and/ or pop-up services. However, it is generally accepted that some people may prefer to access services out of the local area to preserve anonymity. **Joint Strategic Needs Assessment
- Sexual and Reproductive Health** The purpose of this document is to present a strategic Sexual and Reproductive Health (SRH) needs assessment for the population of Sunderland, with a focus on the need for sexual health services. The primary aims of this JSNA chapter are to:
- describe the distribution and determinants of sexual and reproductive disease and ill-health in the population within the City of Sunderland and
- identify the appropriate means to prevent such disease and promote good sexual and reproductive health for the people of the City of Sunderland. The chapter is structured around key questions that are used to frame a needs assessment:
- What is the need locally, both now and in the future? This question is answered by seeking evidence on the distribution and determinants (risk and protective factors) of sexual health in Sunderland, including demographic profiles. Need is considered as the capacity to benefit from an intervention, as well as the demands placed on services.
- What are the effective interventions? This question is answered by seeking evidence of interventions (primary, secondary and tertiary) that can be judged to be clinically and cost- effective, acceptable and accessible, relevant and equitable.
- What is being done to locally to address this issue and how do we know this is making a difference? This question is answered by reviewing existing sexual health structures (i.e., systems and services), processes (i.e., pathways and interventions) and outcomes (i.e., in promoting good sexual health, and preventing sexual ill health, measured by mortality and morbidity).
- What is the perspective of the public on this issue? This question is answered by seeking the views of residents and service users on their expectations and needs, how this compares with service provision, and using any gaps to formulate ideas on future service provision. Finally, analysis of the answers to each of the questions listed above provides evidence to inform the development of recommendations for commissioning and further needs assessment work. 2) What is the need locally, both now and in the future?
In tandem with the trends in fertility, the population is ageing, which in turn places greater economic demands on the working age population (including females of child bearing age). In Sunderland in 2016, 19% of local population was aged over 65. This is expected to rise to 22% by 2026 and reach 25% by 2036. In the shorter term, ONS have calculated that the number of fertile women in the local population is projected to fall by approximately 2,000 between 2014 and 2018^3 and to level off at around 51,000 thereafter. Analysis of local conceptions data has shown that the rate of conceptions (for the population as a whole and for under-18 year olds) has a positive and linear relationship with deprivation scores. As deprivation increases, so do conception rates. Figure 1: Scatter plot of conceptions in Sunderland by Ward and 2015 IMD score Figure 2: Scatter plot of Under-18 conceptions in Sunderland by Ward and 2015 IMD score (^3) ONS, https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/dataset s/localauthoritiesinenglandtable
Tables 1 to 3 summarise the general demographic picture for Sunderland, including the overall growth of the local population over the next 20 years (again excluding any speculative impact of Brexit). Table 1: Population projections for the City of Sunderland by age group (ONS, 2016)^4 Age Group 2017 2027 % Change 2017 - 2027 2037 % Change 2027 - 2037 <10 years 30,900 30,500 - 1.3% 29,700 - 2.62% 10 - 14 years 14,700 15,300 4.1% 15,300 0.00% 15 - 19 years 15,100 16,300 7.9% 15,900 - 2.45% 20 - 24 years 19,300 17,500 - 9.3% 18,400 5.14% 25 - 44 years 68,500 71,000 3.6% 70,000 - 1.41% 45 - 64 years 76,600 68,800 - 10.2% 64,300 - 6.54%
65 years 53,400 64,200 20.2% 73,400 14.33% Grand Total 278,500 283,600 1.8% 287,000 1.20% Table 2: Population projections for the City of Sunderland by sex (ONS, 2016) Sex 2017 2027 % Change 2017 - 2027 2037 % Change 2027 - 2037 Male 136,200 139,600 2.5% 142,100 1.79% 4 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/dataset s/localauthoritiesinenglandtable
Refusal 0.79% 1.17% Younger people were more likely to describe themselves as other than heterosexual, with the exception of the oldest age group unsure of their sexuality. Table 5: Sexual orientation by age group (ALS, 2017) Which of the following best describes your sexual orientation?
A. Heterosexual or straight
B. Gay 2.23% 2.26% 0.62% 0.59% 1.01% 0.69% 0.22% 0.71% C. Lesbian 1.04% 0.45% 0.62% 0.49% 0.11% 0.00% 0.00% 0.00% D. Bisexual 2.08% 1.58% 0.25% 0.20% 0.23% 0.00% 0.00% 0.00% E. Other 0.00% 0.23% 0.25% 0.69% 0.68% 0.14% 0.00% 0.71% Don't know 0.30% 0.23% 0.12% 0.30% 0.23% 0.28% 0.90% 2.13% Refusal 0.74% 1.13% 0.87% 0.69% 1.24% 0.83% 1.57% 0.71% In the National Survey of Sexual Attitudes and Lifestyles (Natsal- 36 ) study, 97% of men and women defined themselves as heterosexual. Between 1-1.5% described themselves as gay or lesbian, and a further 1-1.4% identified as bisexual. Amongst men, identifying as gay and having at least 1 male partner in the past 5 years were highest in the 25-24 year old age group, with 2.4% and 3.5% respectively. On average, 2.6% of men reported having at least 1 male partner in the past 5 years. Amongst women, identifying as bisexual and having at least one female sexual partner in past 5 years was highest amongst 16-24 year olds, at 2.5% and 6.2% respectively. On average, 3.2% of women reported having at least 1 female partner in the past 5 years. Sexual activity and first sexual intercourse Natsal- 3 has shown that age of first sexual intercourse has been decreasing across generations. 4.0% of 65-74 year olds reported having heterosexual intercourse before age 16. For 16-24 year olds this is 29% (29.2% of women, 30.9% of men). The frequency of recent sexual activity and numbers of partners were highest amongst the younger age groups. (^6) The Natsal is a household survey, with many questions answered by self-report. As such, the survey may exclude the groups most at risk of sexual ill health, including travellers, people in contact with criminal justice services and those without homes. The survey generated a large number of published articles. A key publication used for this section is as follows: Mercer, Catherine H., et al. "Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)." The Lancet 382.9907 (2013): 1781-1794.
On the whole, males appeared to report higher levels of sexual activity. On average, 63% of males reported having vaginal sex in the past 4 weeks. 67% had given or received oral sex in the past year, and 13% had anal sex in the past year (rising to 18.5% in those aged 16-24). On average, 58% of females reported having vaginal sex in the past 4 weeks. 60% had given or received oral sex in the past year, and 10.5% had anal sex in the past year (rising to 17% in those aged 16-24). Amongst males, it was most common to report having 1 partner or less in the previous year (67.1% within all age groups). 33% of 16- 24 - year-old males reporting having 2 or more partners in the previous year, as compared with 20% or less in other age groups. Amongst females, the picture was similar. 68.4% if all female respondents reported having 1 partner or less in the previous year. 27% of 16- 24 - year-old females reported have 2 or more partners in the previous year, as compared with 13% or less in other age groups. Although younger people were more likely to report more frequent recent sexual activity and higher partner numbers (i.e., indicating increasing risk of disease transmission and need for health protection), the prevalence of vaginal sex within the past year was highest amongst those aged 30- 34 years (perhaps indicating greater need for reproductive health promotion and services within this age group). See Figure 3. Figure 3 : Behaviours relating to pregnancy risk in the year before interview. Source: Natsal-3.^7 (^7) Wellings, Kaye, et al. "The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)." The Lancet 382.9907 (2013): 1807-
Figure 4: Sexual and Reproductive Health Profile for Sunderland: PHE, 201 8 In addition to the SRH Profile, PHE North East Centre produces an annual HIV, sexual and reproductive health epidemiology report (LASER). This is based upon data collected through the Chlamydia Testing Activity Dataset (CTAD) and the Genitourinary Medicine Clinic Activity Dataset (version 2) (GUMCAD). These are surveillance systems populated by local clinics and managed by PHE.
Key findings from the latest report (using 201 7 data unless otherwise specified) include the following:
- Overall 1,875 new sexually transmitted infections (STIs) were diagnosed in residents of Sunderland, a rate of 676.1 per 100,000 residents (compared to 743 per 100 , 000 in England).Sunderland has the 90th highest rate (out of 326 local authorities in England) of new STIs excluding chlamydia diagnoses in 15-24 year olds; with a rate of 708.8 per 100,000 residents (compared to 794 per 100,000 in England).58% of diagnoses of new STIs in Sunderland were in young people aged 15- 24 years (compared to 50% in England).For cases in men where sexual orientation was known, 12.9% of new STIs in Sunderland were among gay, bisexual and other men who have sex with men (MSM).
- The Chlamydia detection rate per 100,000 young people aged 15-24 years in Sunderland was 1,6 99 (compared to 1,882 per 100,000 in England).
- Sunderland has the 45th highest rate (out of 326 local authorities in England) for gonorrhoea, which is a marker of high levels of risky sexual activity. The rate of gonorrhoea diagnoses per 100,000 in this local authority was 81.5 (compared to 78.8 per 100,000 in England).The rate of Syphilis diagnoses per 100,000 in this local authority was 4.0 (compared to 10.6 per 100,000 in England).
- In Sunderland, an estimated 6.4% of women and 8.1% of men presenting with a new STI at a sexual health service (SHS) during the 5 year period from 2013 to 2017 were re-infected with a new STI within 12 months.. Among specialist SHS patients from Sunderland who were eligible to be tested for HIV, 77.4% were tested compared to 65.7% in England (HIV testing coverage).There were 9 new HIV diagnoses in individuals aged 15 years and above in Sunderland. The diagnosed HIV prevalence was 0.9 per 1, population aged 15-59 years in people being seen for HIV care resident in Sunderland (compared to 2.3 per 1,000 in England).In Sunderland, between 2015 and 2017, 38.2% (95% confidence interval [CI] 22.2%-56.4%) of HIV diagnoses were made at a late stage of infection (CD4 count =< cells/mm³ within 3 months of diagnosis) compared to 41.1% (95% CI 40.2-42.1) in England. (Please note that the number of late diagnoses (and new HIV diagnoses) are small therefore these figures must be interpreted with caution).The total rate of long-acting reversible contraception (LARC) excluding injections prescribed in primary care, specialist SHSs and non-specialist SHSs was 49.8 per 1,000 women aged 15-44 years in Sunderland, and 47.4 per 1,000 women in England. The rate prescribed in primary care was 15.9 in Sunderland and 29.2 in England. The rate prescribed in the other settings was 33.9 in Sunderland and 18.2 in England. In Sunderland upper tier local authority, the total abortion rate per 1,000 female population aged 15-44 years was 12.5, while in England the rate was 17.2 per 1,000. Of those women under 25 years who had an abortion in that year, the proportion who had had a previous abortion was 19.0%, while in England the proportion was 26.7%.In 2016, the conception rate for under-18s in Sunderland was 31.9 per 1,000 females aged 15- 17 years, while in England the rate was 18.8. Further analysis of the GUM data has shown that during 2014-2017, new Gonorrhoea diagnoses were fairly evenly split between males and females. However, about a third of female presentations had previously been diagnosed elsewhere - this was less than 5% in male attendances. Of the male attendances, almost a third of patients identified as gay or bisexual, whereas 97% of females identified as heterosexual. Male patients appeared to be older, as the peak age of male attendances was 22 against 18 for females. Of the cases resident in Sunderland, Hendon ward represented the highest number. Further analysis showed that diagnoses in the local population had a moderate
The Chlamydia detection rate is a measure of the level of control activity rather than a measure of morbidity. Public Health England recommends that local authorities should be working towards a detection rate of at least 2,300 per 100,000 population aged 15-24. The Chlamydia detection rate has been falling in Sunderland since a peak of 2,572 per 100,000 population aged 15-24 in 2013. In 2016 the Chlamydia detection rate was 1,654. This is significantly worse than the regional (1,836) and national (1,882) positions. Sunderland ranks second worst for this amongst statistical neighbours and fourth lowest regionally. The Chlamydia detection rate for females has fallen from 3,536 per 100,000 population in the first quarter of 2013 to 2,088 per 100,000 population in the quarter to September 2017. For males, the Chlamydia detection rate has fallen from 2,183 per 100,000 population in the first quarter of 2013 to 1,143 per 100,000 population in the quarter to September 2017. Data from January 2013 to end September 2017 ( see Figure 6 ) shows that whilst the number of Chlamydia tests reported has been falling, the proportion that are positive has fluctuated around 9.5% overall for all persons aged 15-24. At September 2017, the proportion of tests that were positive in Sunderland was 11.2%. This suggests appropriate targeting for testing, but not enough throughput of screening to achieve the required detection rate of at least 2,300 per 100,000 population. Figure 6: Quarterly Chlamydia Tests and Positivity, CTAD, 201 8 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% Q1 2013 Q3 2013 Q1 2014 Q3 2014 Q1 2015 Q3 2015 Q1 2016 Q3 2016 Q1 2017 Q3 2017 Female test coverage rate Male test coverage rate Linear ( Female test coverage rate) Linear (Male test coverage rate)
It was not possible to analyze local data on late HIV diagnoses without access to the HIV and AIDS Reporting System (HARS). Further local investigation may be necessary. PHE’s recent publication on HIV and AIDs found an 18% decline in new HIV diagnoses between 2015 and 2016, due to range of factors including STI prevention and availability of pre-exposure prophylaxis (PrEP)^10. The rate of positive STI diagnoses as published in the SRH Profile and LASER may not be a good indicator of the burden of disease in the local community, as this depends on underlying prevalence as well as the rate of testing. The SRH profile data shows that excluding Chlamydia, Sunderland tests around 11% of the eligible population for STIs – having fallen from 12% in 2012 and risen to nearly 13% in 2014 (see Figure 7 ). Figure 7: Rates of STI testing and diagnoses for under-25s (excluding Chlamydia): PHE, 2017 (^10) https://www.gov.uk/government/statistics/hiv-annual-data-tables
Poor health is independently associated with decreased sexual activity and satisfaction at all ages and mental ill health such as depression is associated with poorer sexual health^12. People with learning disabilities may be less likely to engage in sexual activity in part due to protection from perceived risks by social agents (information sourced from conversation with local service provider). Men who pay for sex are at greater risk of STI acquisition and onward transmission than men who do not^13. People who engage in anal sex (oral and genital) are at risk of contracting Sexually Transmitted Enteric Infections (STEIs) such as shigella, giardia, campylobacter and salmonella. As noted above, cases involving MSM represent almost 13% of new STI diagnoses, but the prevalence of men having a male partner may be as low as 3%. Many health outcomes have a clear association with area-level deprivation, including overall life expectancy and premature mortality, obesity in children, alcohol-related harms, smoking prevalence and smoking-related deaths, and conception rates (as noted above)^14. This relationship has also been observed for many sexually transmitted and blood-borne infections such as Chlamydia^15 , hepatitis B and C, HIV, Gonorrhoea, syphilis, and genital warts^16. There is evidence that circumcision can reduce the risk of disease including HIV, HPV, chancroid and syphilis^17. Receiving relationships and sexual health information at school is associated with reporting better sexual health outcomes, including later age of first sexual intercourse and sexual competence^18. Research undertaken by Changing Lives on women involved in sex work in 2011^19 (in Sunderland and Newcastle) and 2015^20 (in Durham and Darlington) has shown that many worked opportunistically to (^12) Field, Nigel, et al. "Associations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)." The Lancet 382.9907 (2013): 1830-1844. (^13) Jones, Kyle G., et al. "The prevalence of, and factors associated with, paying for sex among men resident in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)." Sex Transm Infect (2014): sextrans-2014. (^14) The PHE fingertips tool can be used to create a scatter plot showing the correlation (or lack of) between deprivation and any selected health outcome. (^15) Sonnenberg, P., et al. "Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal) Lancet. 2013; 382 (9907): 1795–806. doi: 10.1016." S0140-6736 (13) (1795): 61947-9. (^16) Hughes, G. J., and R. Gorton. "Inequalities in the incidence of infectious disease in the North East of England: a population-based study." Epidemiology & Infection 143.1 (2015): 189-201. (^17) Homfray, Virginia, et al. "Male circumcision and STI acquisition in Britain: evidence from a national probability sample survey." PLoS One 10.6 (2015): e0130396. (^18) Macdowall, Wendy, et al. "Associations between source of information about sex and sexual health outcomes in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)." BMJ open 5. (2015): e007837.
pay for drugs, food or receive accommodation. Childhood trauma, mental health problems, substance misuse, homelessness, domestic abuse and loss of custody of children were all common features of these women’s lives. Although escorts were less likely to have complex needs violence, sexual assault and rape were commonly experienced by all of the women interviewed regardless of the type of sex work they conducted. Few women reported negative impacts on sexual health in terms of communicable disease infection. High levels of condom use and accessing GUM were reported. Participants reported that sex work had impacted negatively on sexual relationships with partners, finding sex work had devalued their self-esteem and made intimacy difficult and intercourse unfulfilling. There was a tendency to use substances whilst working. Most were accessing substance misuse treatment services. Women subject to child exploitation often showed low levels of understanding about what exploitation is and how they had been groomed as part of their exploitation. In summary of the above:
- The total fertility rate in the local population is insufficient to reproduce the population by itself.
- The fall in fertility rates is due to a combination of general factors that could be outside the control of the local authority.
- Higher conception rates (including under-18s) are associated with increasing area-level deprivation.
- Poorer health including sexual health is associated with increasing deprivation, including education, income and employment.
- Certain groups are more vulnerable to poorer health and sexual health outcomes due to a combination of biological, behavioural, environmental and service-related factors. This includes people who experience higher area-level deprivation, engage in other risk taking behaviours and lack sexual health literacy and agency for various reasons. Specific groups include young people, asylum seekers, people with learning disabilities, people in contact with CJS, sex workers, communities exposed to high levels of deprivation. The complex needs of individuals in such groups may require capacity building within their primary service provider, and an improved interface with SRH services including outreach.
- There is anecdotal evidence of increasingly experimental sexual behaviours, especially amongst young people.
- Sunderland has a relatively high rate of teenage pregnancies, which is being addressed through a renewed local strategy.
- The City has a relatively low rate of LARC prescribing in primary care settings, which may be slightly offset by fitting in specialist settings.
- Sunderland has a comparatively low rate of STI testing, which in turn may lead to relatively low rates of positive diagnosis including Chlamydia.
- There is a continuing decline in the Chlamydia diagnostic rate, which needs to be considered in any future commissioning models.
- Sunderland has a relatively high rate of late HIV diagnoses which, although the numbers are small, may require further local investigation. (^19) Irving, Adele and Laing, Mary (2013) PEER: Exploring the Lives of Sex Workers in Tyne and Wear. Project Report. The Cyrenians, Newcastle-upon-Tyne. (Unpublished) (^20) http://www.changing-lives.org.uk/news/peer-research-sex-durham-darlington/
