A note from Marge Berer to potential applicants for the job of RHM Editor

RHM seeks to appoint a new editor in 2015 and the application process is now open. Founding Editor, Marge Berer, has written this note to potential applicants:

Being the editor of Reproductive Health Matters has been an incredible experience. I’ve not only been able to be a full-time editor in this job, but also a lecturer, sharing the knowledge that RHM has published, and a teacher of writing for publication. I’ve also always done this job as an active participant in the field and as an advocate for sexual and reproductive health and rights. In the 22 years since we started the journal, I’ve had the privilege of working with hundreds of the most amazing authors and peer reviewers anyone could hope to meet.

With readers in 186 countries and the support of RHM’s donors, boards and authors, RHM has become a much valued resource in the field for information, knowledge, perspectives, ideas for change on the ground, and recommendations for policy, services, research and action.
The world of journal publishing is increasingly complex and RHM faces a period of transition to online publishing and changes in relation to open access publishing that raise new and different equity-related issues from the past.

Funding will always present a challenge.

However, RHM’s unique perspective, determination to cover controversial, new and neglected issues and challenge orthodoxies is needed now more than ever. I look forward to welcoming someone with the passion and skill to meet these challenges who will take RHM into the future with new ideas and energy.

Details of the job and how apply

The future as envisioned by WHO for the post-2015 agenda: a serious regression from its long-standing commitments on sexual and reproductive health and rights

Marge Berer

Editor, Reproductive Health Matters

What has gone wrong at WHO? The Lancet’s Offline report (31 May)  of what they call “WHO’s definitive statement about the future it envisions for the post-2015 era of sustainable development” signals a serious regression by WHO away from championing its own policies of many years, and makes for a distressing read. Among the policies WHO should be promoting for the post-2015 agenda setting must surely be:

i) the right to the highest attainable standard of health, as one of the fundamental rights of every human being, a goal which has underpinned WHO’s work since it was founded in 1948,

ii) universal access to sexual and reproductive health and rights, and

iii) strengthening of health systems, taking into account the social and economic determinants of health.

“Universal access to sexual and reproductive health and rights” is in line with WHO’s 2004
Reproductive Health Strategy, approved by the 57th World Health Assembly  and reflects more than four decades of work by the Special Programme of Research, Development and Research Training in Human Reproduction (HRP), based at WHO, and most recently a resolution at the 67th World Health Assembly.

The most important international bodies and leaders currently support the inclusion of universal access to sexual and reproductive health as a crucial goal in its own right under the overarching health goal in the post-2015 agenda, and add reproductive rights to this also under gender equality. The Stockholm Statement of Commitment agreed by 260 Parliamentarians from 134 countries at the Sixth IPCI/ICPD Conference in April 2014 states that access to sexual and reproductive health and rights is an ‘indispensable component’ of the post-2015 development framework. On July 4th a letter from Parliamentarians around the world addressed to Dr Margaret Chan, Director General of the WHO, expressed their concern about the omission of reproductive health and ‘strongly’ support for the Stockholm statement.

Moreover, in consultation after consultation, numerous national and international civil society organisations have called for the inclusion of reproductive and sexual health and rights as an integrated whole as well.

It is a serious mistake on WHO’s part to try to bury this issue under Universal Health Coverage, where it will get lost in a sea of competing finance-oriented interests. To do so discounts the consistent support for these goals by the World Health Assembly as well as the work of countless WHO staff and expert advisors.

There are other indications of a systematic pushback and regression away from work on sexual and reproductive health and rights at WHO as well. It is not reflected as a priority in the 12th WHO Global Programme of Work, nor in the just published Health for the World’s Adolescents, an unprecedented omission. This cannot be taken lightly.

Friends of WHO must do everything they can to ensure WHO assumes its leadership role on these issues again and does not fall back on its longstanding commitments.

HIV prevention with PrEP – cost, power and sexuality: questions still to be addressed

Sian Long, News Editor

On 14 May, the US Public Health Service released guidelines for pre-exposure HIV prophylaxis (PrEP)– the first comprehensive guidelines in the US. The guidelines recommend that HIV-negative people at ‘substantial risk for HIV’ take antiretroviral drugs on a daily basis, alongside condom use. Substantial risk includes anyone who is in an ongoing relationship with an HIV-positive partner and anyone who is HIV-negative and not in a mutually monogamous relationship and who is either a gay or bisexual man who has had anal sex without a condom or been diagnosed with an STD in the past 6 months or, a heterosexual man or woman who does not regularly use condoms during sex with partners of unknown HIV status who are at substantial risk of HIV infection because they inject drugs or have bisexual male partners. It also includes people who have injected non-medical drugs and who have shared injection equipment or been in drug treatment for injection drug use in the past 6 months.

The guidelines are based on strong evidence from clinical trials of PrEP use in high-risk populations. These trials found that HIV transmission risk was lowest for participants who took the pill consistently, with reductions in risk ranging from around 40%-as much as 90% for gay and bisexual men and both heterosexual men and women. Reductions approximately halved among injection drug users. The only pill that has been endorsed for use in the US guidelines is a combination pill of two drugs, taken once a day. In the US, the drug is called Truvada and is made by Gilead Sciences. The generic version of Truvada is made in India and is widely used in low-income countries.

So far, so good. But this protocol raises many questions about cost, power and sexuality.

Advocates of HIV prevention in the US have welcomed the guidance. Condom use is going down and unprotected sex is rising amongst gay men. Arguably, HIV-negative men and women, gay and straight, who feel unable to insist on condom use with partners may find that this is a viable form of protection. However, taking a daily – and currently very expensive pill – is a very expensive, medical response to the problem. Although the drug is available in cheaper, generic version in India and sold widely globally, it is still immensely expensive to take a daily drug. Add on to this the costs of training staff to identify and support those who are ‘at risk’ – often those who are most discriminated against and least comfortable to use a health service – and the costs not only of the drug, but delivery and monitoring are huge.

Many doctors and activists are also concerned about the ethics of providing a daily pill to people who are healthy – for the rest of their life. Relying on an expensive drug also makes it easier to stop investing in safer sex campaigns – those that acknowledge and seek to address issues such as gender inequity in relationships. Safe sex in relationships is not just about preventing HIV – it is about improving equality and pleasure. A pill will not do this alone.

Will the drug be available to those who are most likely to need it – people who have limited power to say no to sex? Gay men and transgender people who are refused access to treatment – and who in some countries face imprisonment for even acknowledging who they are. Ugandan parliamentarians, who have already passed through one of the world’s most hate-filled homophobic laws – have expressed concern about Truvada ‘on moral grounds’, saying that it could encourage ‘reckless sex’.

However, there are also many advocates across Africa, Asia and Latin America who see this as a way of supporting women, men and transgender people who are at great risk of HIV and whose HIV prevention needs have been consistently overlooked – sex workers, young gay men, transgender people – and whose HIV rates are much higher than the ‘general population’.

It is clear that a debate must be opened on this; and that the rights of young men and women and of transgender people in countries where HIV treatment itself is hard to reach and where public health systems are fragile, must be at the forefront of this debate.

**************************************************************************

For up to date information on ART for prevention of HIV transmission:                                 NAM/European AIDS Treatment Group Community consensus statement on the use of antiretroviral therapy (ART) to reduce the risk of HIV transmission from people living with HIV (also published in full in RHM43)

All RHM papers published up until May 2013 are now free to download, many papers on HIV, include:                                                                                                                                  The introduction of new antiretroviral-base HIV prevention methods into health systems: key issues                                                                                                                                          Rape and HIV Post-Exposure Prophylaxis: addressing the Dual Epidemics in South Africa

a supplement including 13 papers on The pregnancy decisions of women living with HIV     and many more…

 

‘The death of a woman due to pregnancy complications is not only a biological fact; it is also a political choice’

Lisa Hallgarten, Online Editor

As people around the world celebrate Mother’s Day we reprint a blog, originally published in May 2012  on the Bererblog to coincide with the publication of RHM39 ‘Maternal mortality or women’s health’ (all papers in this journal and all journals over one year old are now free to download)

In 2008 UK spending on Mother’s Day gifts may have amounted to as much as UK£1.6bn, while last year it was estimated that consumers in the United States would spend as much as US$16bn.

This contrasts sharply with spending on basic life-saving care for mothers in much of the global South – with some countries spending less on all health services per head of population per year than some people will spend on their Mother’s Day bouquet.

With just 3 years left to meet Millennium Development Goal 5a (reducing the maternal mortality ratio by 75% between 1990 and 2015), there is still a long way to go. As many as 94% of women in some of the poorest urban populations still give birth with no skilled birth attendant and have no access to emergency obstetric care if complications arise.

Reproductive Health Matters is dedicating its May issue to the subject of maternal mortality and asks whether the rhetoric of ‘safe motherhood’ is finally being matched by resources and action. Articles include:

An analysis of unsafe abortion differentials by age in developing countries which finds that younger women, especially adolescents, are disproportionately at risk of accessing unsafe abortion.

An investigation into maternal deaths in Madhya Pradesh, which finds drastic shortfalls in both antenatal and maternity care and questions the impact of government schemes to incentivise access to health facilities during birth.

An analysis of Demographic & Health Survey data for Egypt and Bangladesh which finds that improvements in antenatal care to be found in many countries are not matched by improvements in post-partum and post-natal care – still grossly neglected areas.

An article on the role of delaying care on maternal mortality and morbidity, which explores the importance of understanding women’s ‘road to death’ by combining the three delays framework and the ‘near miss’ approach. The challenges we face in trying to meet the Millennium Development Goal for maternal mortality are enormous, but as the authors of this paper note, the biggest obstacle to change is neglect and discrimination:

‘Understanding maternal deaths as a consequence of neglect implies the recognition that it is due to the disadvantaged position of women in society, including with regard to their reproductive rights. Only women experience the inherent risks of reproduction; this is a matter of sexual difference. However the lack of appropriate reproductive health care is a matter of gender discrimination and a consequence of a social system “based on the power of sex and class”. Gender discrimination occurs in all stages of women’s lives: preference for boy children, neglect of care for girls, poor access to health, and maternal mortality. The death of a woman due to pregnancy complications is not only a biological fact; it is also a political choice that is amenable to change and within human grasp. It depends above all upon political will.’

Subscribe to Reproductive Health Matters (free subscriptions are available for institutions in the global South)

Follow RHM on Twitter

Like RHM on Facebook

 

Repeat abortion: is it really a problem?

Lisa Hallgarten, RHM Online Editor

Marie Stopes International yesterday published research findings on the contraceptive use of women in the UK aged 16-24 having one or more abortions. Abortion is now accepted by the majority of the UK population as a legitimate option for women facing an unintended or unwanted pregnancy, and an essential aspect of health provision. Safe abortion can be attributed with saving women’s lives and preserving their health wherever in the world it is accessible. Abortion is, despite the lingering stigma and objections of a small minority, generally believed to be a beneficial service. ‘Repeat abortion’ however, has more negative associations. To paraphrase Oscar Wilde, to have one abortion may be regarded as a misfortune – to have two looks like carelessness.

When I and a colleague at Education For Choice undertook research into the phenomenon of repeat conceptions leading to repeat abortion amongst teenagers in 2007, it became clear very quickly that the term ‘repeat abortion’ is a misnomer. It suggests that a woman is in some way thoughtlessly or compulsively repeating a negative action, whereas the truth is that each abortion is a separate and unique event in a woman’s life. Whether her abortions take place within a year, or twenty years apart, her circumstances, health, the status of her relationship and her emotional attachment to the pregnancy may all be very different. The way in which she got pregnant, her chosen method of contraception and consistent or inconsistent use of that method may also have changed from one unintended pregnancy to the next. Having a ‘repeat abortion’ may engender feelings of guilt at ‘failing’ to prevent a second pregnancy, or it may feel safe, straightforward and familiar the second time round. When we talk about ‘repeat abortion’ we make this complexity and the stories of women’s real lives invisible.

Healthcare providers we interviewed expressed discomfort about their experience of referring women for second or subsequent abortions, but this was often an expression of their commitment to good quality care and anxiety not to let women down. When a woman presents to request abortion, it is standard practice to discuss her past contraceptive use and her plans for future contraception. Abortion referrers and abortion providers often feel a sense of professional failure when a woman presents for a further abortion. They wonder if they could have done more to advise her effectively about the range of contraceptive methods; they wonder if they could have given her more time to consider the pros and cons of each method in relation to her own needs, lifestyle, relationship and body; they wonder if they should have followed up the woman who said she needed more time to think about it, or could not get her chosen contraception at the time of the abortion. Women too may internalise this feeling of failure, ‘I could have done better, chosen better, stuck with that contraception method even though I hated how it made me feel’.

Feeling bad about a first or ‘repeat’ abortion is not a good basis for making a positive choice about future contraception. It can result in feelings of fatalism (which is very bad for decision-making); lack of trust in service providers or feeling untrusted by them; or agreeing to, rather than positively choosing, a recommended method of contraception. Likewise professional anxiety about preventing future unintended pregnancy may result in promoting, rather than offering, long acting reversible contraceptive methods. So, I applaud Marie Stopes’ recognition that abortion stigma is a problem.

I only wish that we could lose the idea that the most effective way to reduce stigma is by reducing the incidence of ‘repeat abortion’. This idea reinforces the messages from politicians, funders and the media that tell us ‘abortion just about ok, repeat abortion bad’. But what if we can’t eradicate ‘repeat abortion’ simply by improving contraceptive services? What if, as our research found, women’s complex and sometimes chaotic lives and relationships play as much part in unintended conceptions as contraceptive provision or lack of it? What if, as is increasingly being articulated, there are women who simply cannot find a contraceptive method that works for them. Shouldn’t we focus on reducing the stigma of ‘repeat abortion’ in and of itself?

Abortion is not the onerous journey it once was: the procedures can be provided very early and are extremely safe. If a woman feels happiest using a less reliable contraceptive method such as condoms and doesn’t see having one, two or three abortions across her 35 fertile years as a problem, why should we?

Links to research:

Marie Stopes International research with women experiencing one or more abortion, 2014

Reducing repeat teenage conceptions: a review of practice. Hallgarten and Misaljevich, 2007

Young people in London: abortion and repeat abortion. Hoggart et al, 2010

 

Reflections on the recent arrest in London of two people for female genital mutilation (FGM)

Marge Berer, RHM Editor

Last month an obstetrician-gynaecologist and the husband of a patient at the Whittington Hospital in London were charged with the crime of female genital mutilation (FGM) because of a procedure carried out on a woman, following childbirth, who had previously experienced FGM.

This is the first prosecution for FGM in the UK since it was criminalised in 1985 and the law further amended in 2003. This fact may suggest that the Crown Prosecution Service (CPS) have been too circumspect before now in bringing a prosecution. On the other hand, do they think the current case is watertight, given that the woman will have needed some kind of repair following delivery of her baby? Part of the problem is that the lack of previous prosecutions and recent highly emotional and effective campaigning by a new generation of anti-FGM activists may have put pressure on them to bring the only case they felt had a chance of success, even one which may not stand up to legal or clinical scrutiny further down the line.

The decision to make the arrests was celebrated by veteran anti-FGM campaigner Efua Dorkenoo, who was reported on the website of the International Federation of Gynecologists and Obstetricians to have “welcomed news of the first prosecution relating to the procedure in the UK”. At the same time, an article by Sarah Ditum in the New Statesman on 24 March, asked why the first prosecution took 30 years since the law was first passed. Neither woman addressed the details of the actual case, which were unknown, nor whether it was the right place to start.

However, a letter from a group of distinguished, senior obstetrician-gynaecologists, published in the Guardian soon after the arrests, said that for pregnant women whose external genitals had been cut and stitched together, leaving only a small hole for urination and menstruation, defibulation (that is, opening the stitching), is required for them to give birth, and then after the birth, some form of repair is also required. The Crown Prosecution Service are well aware of this, and that the law exempts such repair from prosecution. Indeed, its website with legal guidance on FGM states:

“No offence is committed by a registered medical practitioner who performs a surgical operation necessary for a girl’s physical or mental health… but only if the operation is on a girl who is in any stage of labour, or has just given birth, and is for purposes connected with the labour or birth.”

While it is also “an offence under the Act for any medical professional (or anyone, for that matter) to reinfibulate or close a woman after she has been defibulated during labour for childbirth” this is diffferent from needing to repair the tissue itself. According to this, obstetricians and midwives should have nothing to fear from providing necessary treatment to a woman who has been deinfibulated before or during labour and needs some kind of suturing afterwards. The signatories to the Guardian letter believe that this prosecution, which may be about this very kind of repair, will create a climate of fear for obstetricians and tie their hands when it comes to providing necessary (and sometimes life-saving) care to women who have had FGM in the past.

This case may hinge on whether the procedure carried out was in fact necessary clinical care or actually went further, in particular, by reinfibulating the woman (i.e. sewing her labia together again, effectively reinstating the FGM, which is against the law). This uncertainty suggests that the guidelines (or their interpretation by the CPS) may not sufficiently distinguish between suturing intended to result in reinfibulation, and suturing to prevent bleeding and accelerate healing for a woman whose infibulated vulva has been cut open to make childbirth possible.

The last thing we need in the UK is to obstruct the very medical professionals who have the skills to help pregnant women with the more severe forms of FGM to have their babies safely without resorting to a caesarean section.

For answers, we must await further details of the case. In the meantime, the conflicting reactions of people who are in fact united in their concern for women’s health and their opposition to FGM itself, serve to demonstrate what a blunt instrument the law may be when dealing with a practice such as FGM.

Action against FGM has been taking place in almost every country where it is practised for up to 20-30 years now. According to a comprehensive review by UNICEF, published in 2013, signs of change – reduced prevalence, more local opposition, especially among younger people, less damaging forms of FGM being used, including symbolic pricks and nicks in the clitoris − are finally appearing in a growing number of countries. But change has been slow because girls and women who do not have FGM have simply not been marriageable. Prosecution has rarely been tried in spite of laws against FGM in many places, both in Africa and Europe, because it is believed by many that far from stopping the practice, this would only push it underground. A recent RHM article from Tanzania (1) corroborates this, reporting on the claim by several ethnic groups that FGM has had to be continued in spite of the law to prevent a new form of genital infection, not for its own sake.

Prosecution or doing nothing are not the only two options. Calling for mandatory information in sex education classes is a bit difficult when sex education itself is not mandatory, thanks to government fears of conservative criticism. How to educate ourselves more needs to be debated and discussed, and needs to reflect the knowledge and expertise of those within the communities where FGM is practised. For example, the call from activists from those communities to designate FGM as “child abuse” instead of a cultural practice was extremely powerful.

Those activists believe that prosecution is a necessary part of the package of actions to stop FGM. However, it is important that prosecutions do not push the practice further underground or inadvertently have a negative impact on those health professionals whose practice supports women with FGM to come through childbirth safely, or to restore genital health and sexual pleasure in spite of the previous mutilation (2).

Post Script (16th April 2014)

This case was heard at Westminster Magistrate’s Court on 15th April 2014 and was referred to Southwark Crown Court to be heard on the 2nd May.

(1) Ali C, Strømb A. ‘It is important to know that before, there was no lawalawa.’ Working to stop female genital mutilation in Tanzania. Reproductive Health Matters 2012; 20 (40):69-75 Doi: 10.1016/S0968-8080(12)40664-4).1.

(2) Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. Lancet. 2012 Jul 14;380(9837):134-41. doi: 10.1016/S0140-6736(12)60400-0. Epub 2012 Jun 12.

A selection of RHM articles on FGM, labial surgery and cosmetic surgery:

The limited effectiveness of legislation against female genital mutilation and the role of community beliefs in Upper East Region, Ghana

Female genital mutilation/cutting and issues of sexuality in Egypt

Views of women and men in Bobo-Dioulasso, Burkina Faso, on three forms of female genital modification

Labia reduction for non-therapeutic reasons vs. female genital mutilation: contradictions in law and practice in Britain

Genitals and ethnicity: the politics of genital modifications

Cosmetic surgery, body image and sexuality

These topics have been covered extensively in RHM. All RHM papers older than one year are now free to download from RHM-Elsevier.

May the force go with you! Dilys Cossey rallies the troops at the UK Sexual Health Awards

In March this year Dilys Cossey accepted a lifetime achievement award for her services to sexual health at the UK Sexual Health Awards - run by the UK’s two leading sexual health charities, Brook and FPA. We are reprinting her acceptance speech here with her permission. Her award, shared with David Paintin, another tireless campaigner for women’s reproductive rights, is well-deserved. Her speech reminds us all of how far we have come and how far we still have to go to secure sexual and reproductive health and rights for all. Congratulations Dilys!

It is a great pleasure and honour to accept this award and to receive it with my long-term colleague David Paintin. I have known David for half a century – we started off together in the Abortion Law Reform Association in 1964. It has been a huge privilege to be a member of the team working for so long in this field with committed colleagues – with people like David and Ann Furedi. There was never any doubt about the value of what one was doing.

It is a particular pleasure because it comes from friends and colleagues in FPA and Brook known over many years. I have always valued Simon Blake’s attentiveness and courtesy to a Brook ‘oldie’. And Audrey Simpson and I go back a long way in FPA and Brook. I would like to congratulate both of them: Audrey on her persistence in tackling the thorny issue of the precise legal status of abortion in Northern Ireland, and Simon for his imaginative and confident leadership of Brook and piloting change in choppy waters.

I would also like to say thanks to Ann: she and I had unforgettable years working together in the Birth Control Trust fighting the forces of darkness.

It is good to see here tonight a few familiar faces: Alison Hadley, Harriet Gill, Mary Crawford, Jackie Boath and Jane Hughes. These are the people who have made Brook work so well at the grassroots.

This year Brook is 50. Next year is the FPA’s 85th birthday and in four years time Bpas will be 50. So, as everyone is getting older, just as I am, Simon granted me a special dispensation to say a few words. I thought it would be appropriate to make some observations about how times have changed.

In sexual health terms the 1950s, when I was growing up, were the Dark Ages. Contraception was not part of NHS provision – it was patchily available for married women through FPA and some local authority clinics; abortion was illegal (Mike Leigh’s film Vera Drake is an excellent illustration of the situation); male same-sex relationships were illegal; divorce was difficult and expensive; there were two choices for single young women who got pregnant: a shotgun marriage or giving up your baby for adoption. Many resorted to backstreet abortion. Some gay men committed suicide. Looking back sex, other than in heterosexual marriage, was closely connected with guilt, fear and shame.

Set against that background, my experience in 1961 just before I got married of visiting the FPA clinic in Walworth, South London, later a Brook clinic, is unsurprising. Alas, I did not sport a sparkling engagement ring on the third finger of my left hand, and the volunteer receptionist was suspicious, to say the least, thinking I was up to no good. So, she grilled me not only on my personal details, but those of my intended, and of the date, time and place of our nuptials and our future address. Reluctantly I was allowed in and joined other women sitting minus knickers, suspender belts and stockings. I finally got my diaphragm and cream, after a couple of brisk questions from the doctor about enjoying sex and when I was going to have a family. I subsequently learned that care had been taken to check whether I actually did get married.

But things were beginning to change. The sexual Zeitgeist is captured in the opening lines of Philip Larkin’s poem, “Annus Mirabilis”:

Sexual intercourse began
In nineteen sixty-three
(which was rather late for me) –
Between the end of the Chatterley ban
And the Beatles’ first LP.

The 1960s were a period of substantial social and sexual reform – mainly in the 1966-70 Labour government under Harold Wilson – and set the legal framework still broadly in place today for abortion and same-sex relationships. I was witness to Brook’s birth at the FPA 1964 AGM, and over the years it has grown into a sturdy adult. In the 1970s contraception became available free-of-charge on the NHS – and by some miracle remains so. But the sands constantly shift: in the 1980s HIV AIDS was a huge challenge, as were Mrs Gillick’s legal action against the Department of Health and the anti-abortion lobby’s bitter opposition to legalisation of embryo research. Section 28 was a long, long struggle. Financial cuts and structural changes in the NHS continue to threaten provision. And the issue of sex and personal relationships in education remains unresolved.

Although society and its attitudes have changed profoundly in the last half-century – I think this is an instance where the phrase ‘Things ain’t what they used to be’ is positive, not negative – there will, in my view, never be a time when one can relax. That is why Brook, FPA, bpas and Education for Choice are so important because they are the main guardians of the legacy. I like the message in the ‘XES: We Can’t Go Backwards’ campaign and Brook’s 2019 aim on sex, sexual equality and sexual health.

At the same time there is, in my opinion, a duty to push boundaries for what we believe in. My personal view is that we should be talking about broadening the terms of reference of discussion on sexuality to include the concept of sexual rights as well as sexual health, and on the abortion front about the decriminalisation of abortion – I think that this is something Wendy Savage will be talking about at the Abortion Rights AGM at the end of March.

Many battles are won, but the war continues. And, looking around, I am encouraged to see so many young people and from such a range of different interests. I am confident that together you are a formidable group. Thank you again for my award. Good luck – may the force go with you!

Dilys

Dilys Cossey accepting her Lifetime achievement award at the UK sexual health awards 2014. Thanks to the UK Sexual Health Awards for the picture and Simon Blake for the transcript