Research into the efficacy and cost-effectiveness of brief, free of charge and anonymous sex counselling to improve (mental) health in youth: Design of a randomised controlled trial

Sexual health of adolescents has gained more attention over the last years [1, 2]. Sexual health is described by the World Health Organisation (WHO) as:

"... a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction 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 sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled [3]".

The past decade has also seen a growing recognition of the existence of romantic relationships, experiences and sexual activities in adolescents [4]. With this attention some developments have taken place that could compromise the sexual health and romantic relationship capacities of adolescents.

The first development is the increasing proportion of young people that have sexual intercourse before the age of 16 [5]. Sexual intercourse before this age is associated with increased risks [6]. Men and women who had their first sexual encounter before the age of 16 show increased regret of this experience [5, 7, 8]. For both, boys and girls, the early onset of intercourse was associated with the experienced pressure by peers, and in girls this was also associated with the lack of control in the process of and during sexual intercourse [5]. Another study found increased rates of coercion to have sex in women who had their first sexual intercourse at a younger age. It is also found that the incidence of sexually transmitted diseases (STD's) was higher for the group who had their first sexual intercourse before the age of 16 [6, 7]. Girls who began sexual activity before the age of 13 were twice as likely to become infected with an STD as girls who started sexual activity after the age of 21. Other associations of early sexual activity were a greater likelihood of becoming a single mother, more abortions, and lower levels of personal happiness [6].

Furthermore the younger a person was at his/her first sexual intercourse the higher the likelihood was of having multiple sex partners (at least five sex partners lifetime or four sex partners during the last six months). Having multiple sex partners is associated with (sexual) risk behaviours such as unsafe sex (not using contraceptives), smoking, drug- and alcohol use [8‐11].

As mentioned before, unsafe sex is a common risk factor among adolescents and young adults. It has been found that only in the US, in 19 million new STD cases that occur every year, half of these are in individuals between 15 and 24 years of age [12]. Pregnancy is of course another consequence of unsafe sex. Darroch, Frost and Singh (2001) found that the US has the highest pregnancy and birth rate in women between 15 and 19 years compared to other developed countries. These higher rates arise primarily because of less, and probably less effective contraceptive use [13].

It is well known that mood disorders, and especially major depressive disorder, are among the most common mental disorders in adolescence [14‐16]. Mental disorders, including depression, play a role in the development of sexual risk behaviour and sexual health problems [17, 18]. Sex- and drugs-related behaviour predicts an increased likelihood of depression. Among girls, both experimental behaviour patterns (experimenting with sex, drugs and alcohol) and high-risk behaviour patterns (excessive drinking and/or drug use, and unprotected sexual contact) were found to increase the odds of subsequent depression. Among boys only high-risk behaviour patterns increased the odds of the development of subsequent depression [19].

Romantic attractions, activities (dating, kissing, more than kissing (like touching each other), etcetera) and relationships were also associated with a greater risk of depressive symptoms in adolescence [4, 20]. Adolescents who had romantic relationships and who engaged in romantic activities, compared with adolescents who had not, reported increased depressive symptoms over time [21]. Several models have been proposed to explain this association. For example, the attention impairment model [22], suggests that romantic activities takes attention away from other important areas of functioning and so causing impairment, which increases the risk for depressive symptoms. Impairment of romantic functioning (interpersonal skills in the romantic domain) impaired by depressive symptoms can furthermore have far reaching consequences for the relational development of adolescents [4].

Another study in 7^th-12^th grade students, age 13 to 18, found that depressive symptoms were associated with increased sexual risk. Among boys depressive symptoms were associated with non condom use at last sexual intercourse, among both boys and girls it was associated with a history of STD [17, 23]. Thus, the relationship in adolescents and young adults between sexual behaviour and sexual risk behaviour on the one hand, and psychopathology, particularly depression, on the other hand, appears to be bidirectional.

In the Netherlands, adolescents are - in general - sexually healthy but there are some alarming developments. Bakker, et al. (2009) examined the sexual health of 6428 men and women between 15 and 70 years old (girls 15-18 years old N = 443; boys 15-18 years old N = 368). Of the 15 and 16 year olds, 33% of the girls and 25% of the boys had sexual intercourse. At the age of 17-18 these percentages have almost doubled. Girls with a lower education level have significantly more sexual experience than higher educated girls. Of the 15 to 18 year olds, 3.8% of the boys, and 2.9% of the girls have had more than 10 sexual partners up to that point of their lives. Furthermore, 32.6% of these boys and 28.5% of these girls experienced feelings of guilt about their sexual behaviour. Pregnancy and birth control were also examined in this study. Among boys, 1.1% of their female sexual partners had been pregnant and 0.4% had the baby. More of the partners of high-educated men under 26 years of age who experienced unwanted pregnancy had abortions than low educated men, but the partners of the latter more often gave childbirth. Among girls, 3.7% had been pregnant and 0.8% had the baby. Low educated girls under 26 years of age had more (unexpected) pregnancies, children, and abortions than high educated girls. Among boys, 58.9% uses no contraceptives, while this is the case for 40.9% of the girls. Sexual victimization is more common among girls than among boys (20.2% vs. 2.3%) [24]. Comparable results have been found in other studies in the Netherlands [1, 25].

To improve this situation the Dutch national government has created a new service that facilitates assistance in the area of young peoples' sexual health. The core is a nationwide network of sexual health service provision centres (called 'Sense') for young people up to 25 years of age with questions concerning or problems with sexual health. The regulation builds on the experiences of the pilot version of Sense (pilot from 2005-2008), which was situated in three areas. One of them being the southern South-Holland (sSH) region. In the pilot version of Sense sSH, the Rotterdam-Rijnmond Public Health Service (PHS) identified an omission. Referral of adolescents with sexual health problems could not be performed adequately; the threshold for referral is too high (for example too expensive, too far away, etcetera). Research has shown that not everyone who needed help or advice for sexual health issues actually sought or had access to that help. The unfamiliarity with the available resources is one factor. Furthermore, the lack of trust in the available help, the costs, and reluctance of the help-seeking person are factors that play a role [24]. This implies that a large group of young people who need help for sexual issues have no access to the necessary care. For this reason the Rotterdam-Rijnmond PHS has, in addition to Sense, appointed a sex counsellor who helps to address the sexual problem in a maximum of three, free of charge and anonymous consultations of 45 minutes maximum. This service is called brief sex counselling. Its aim is to provide tailored and practical advice and/or reference to specialised health care, and to bridge the gap between Sense and this, more intensive, specialized help.

The earlier mentioned developments [24] regarding sexual health and the related mental health problems [17, 18] form a major problem for youth in the Netherlands. Brief sex counselling might be a solution as it aims to treat the sexual problems of these adolescents in an early stage. Related mental disorders (like depression) would be less likely to develop or escalate. It is expected that brief sex counselling will prevent more serious and chronic problems in the future. However, there is no scientific evidence yet.

Goldmeier and colleagues calculated that, in 2004, the average costs of the treatment of sexual dysfunctions in the UK for women were €417 when delivered by a psychologist and €896 when delivered by a sex therapist [26]. Potentially, a certain proportion of patients with sexual problems do not require this type of intensive and costly treatment, but can adequately and satisfactorily be treated with less intensive and lower-cost alternatives. For instance, in the Netherlands it was estimated that 14% (respectively 56,000 of the extrapolated total of 400,547) of the patients treated in hospital outpatient clinics for sexology and 24% (respectively 80,500 of the extrapolated total of 335,594) of the patients treated in mental health care centres, could be adequately treated with a cheaper, low-threshold intervention [25, 27]. It can be expected that brief sex counselling is a cheaper and more approachable option to treat sexual problems in adolescents than standard sexual health care provided in community mental health services or hospital outpatient clinics for sexology.

There are two main reasons to conduct this study that are related to current policy aims to improve the sexual health in youth. First, it can be assumed that brief sex counselling for high risk groups has a preventive impact on the recurrence of their sexual condition. This would reduce, moreover, the patient flow to more expensive health care in hospitals and mental health care institutions [25]. Second, a secondary prevention effect of sex counselling on mental health problems, in particular depression, is predicted [25, 28].

The objectives of the current study are threefold. The first is the development of protocols for brief sex counselling in the field of sexual health to address problems in sexual functioning in youth. Furthermore a training plan will be developed to train nurses and public health workers to implement these protocols for brief sex counselling. The second objective is to investigate the effects of brief sex counselling on somatic, mental and sexual health. The third and last aim is to investigate the cost-effectiveness of brief sex counselling. We will examine whether brief sex counselling is preferable to more intensive formats of sexual health care and delayed treatment in terms of costs, impact and utilities from a social perspective.

There are some alarming developments regarding sexual health in adolescents. To overcome the threshold in the treatment of sexual problems, brief sex counselling has been developed. It has been used successively since 2006, but research evaluating this intervention is necessary. Therefore, in the current study we will evaluate the (cost-) effectiveness of brief sex counselling for sexual problems of adolescents and young adults under the age of 25 years of age. We shall compare brief sex counselling with an intensive sexological treatment and a delayed treatment condition.

Brief sex counselling is a new treatment with interesting possibilities. It might lower the threshold to seek professional help for sexual health problems, and could prevent health consequences in later life. The current study contributes to the growing literature on sexual health in adolescents and young adults.