• Sexual health

Three per cent of the world's population—214 million people approximately—can be defined as international migrants and nearly half of them are women.1 The most common reason people have for migration is seeking economic improvement. Therefore, economic migrants are, on the whole, young and fit when they arrive in a new country and at an age when sexual activity and partner change is frequent. Emotional isolation is common and they build new friendships and relationships. On this basis, one would anticipate that the sexual health of economic migrants would have been highlighted as one of their major health issues but, unfortunately, it has not. This issue of Sexually Transmitted Infections contains three papers2–4 on the sexual health of Central and Eastern European (CEE) migrants in London within the SALLEE project (Sexual Attitudes and Lifestyles of London's Eastern Europeans).5 These papers show new data on the sexual and HIV risk behaviour of CEE migrants,2 their patterns of genitourinary clinic attendance and frequency of sexually transmitted infection (STI) diagnosis3 and explore the sexual risk of CEE migrant men who have sex with men (MSM).4

These papers highlight some of the methodological challenges faced in trying to minimise information and selection bias when studying migrants' health.6 One of these challenges is the relatively rapid change in the composition of the migrant population, which requires prompt adaptation of the research methods and tools to meet the singularity of the new comers rather than assuming that they will join the ‘migrant’ group. The heterogeneity of migrant populations is a fundamental aspect to take into account; migrants are not all the same, even within people of the same geographical origin. While this may seem to state the obvious, migrants are often lumped in groups that lack meaningful interpretation. As shown by the team from the University College London, the frequencies of the various outcomes they have studied—as well as their risk factors—differ between heterosexual men, and women and MSM, highlighting the relevance of gender roles in the study of migrants' health in general and of their sexual health in particular.7 Another hurdle is the definition of ‘migrant’, which presents some of the challenges described for defining ‘ethnic minorities’.8 9 Defining a migrant is a difficult task, as definitions need to be simple and comparable with other studies.6 Because of these difficulties, many authors fail to provide a definition—the literature is full of examples where this is missing—and many others provide inadequate definitions that hamper comparability across studies. SALLEE provides a clear definition, a CEE migrant is someone who has been born or spent formative years in one of the CEE countries.2–5 Defining the denominator and the sampling frame is virtually impossible for some populations and, for recent migrants, the sampling strategies used for obtaining probabilistic samples from the general population would not be feasible as most will not have permanent addresses and/or will move out rapidly. SALLEE provides important innovations regarding sampling migrant populations, another of the key methodological difficulties.5 Different sampling strategies as well as innovative approaches such as internet samples and the use of extensive social mapping are needed, as illustrated by these three papers. One of the papers provides compelling evidence of the large differences between community samples and clinic-based samples and calls for strengthening links with the community when conducting research on migrants' health.3

The accession of eight CEE countries to the EU in May 2004 (Accession A8) resulted in increases in the number of men and women from these areas attending two central London genitourinary medicine (GUM) clinics from 2004 to 2007 compared with 2001 to 2004,10 identifying a new population that required sexual health services. These eight countries have very different HIV epidemics, however11 12; by 2004, new HIV infection rates were 17 per million in Poland and 557 per million in Estonia.12 Romania and Bulgaria joined the EU in January 2007 (Accession A2) and their HIV epidemics are also very different.11 12 It has been well documented how from the mid- to late 1990s onwards, some—but not all—countries conforming to the former Soviet Union witnessed explosive HIV epidemics transmitted through unsafe injecting drug use, and the transition to the heterosexual population was facilitated by emerging high rates of syphilis and other STIs.11 12 Data on HIV infection in MSM in these regions was poor most likely due to the invisibility and the lack of rights of these men. The decision to analyse all A8 countries together, as well as the A2 ones, is discussed in the papers, but the authors have included people coming from very different epidemiological contexts in the same group. Of the 1225 GUM patients studied by Evans et al,3 as many as 40% came from Poland while as few as 2% came from Estonia, so this categorisation over-represents the risk of the Polish migrants rather than migrants of the A8 countries.

These papers provide new data on the sexual health of CEE male and female migrants and demonstrate fundamental gender differences as the authors have taken the decision to stratify by sex. Rates of STI diagnoses are lower in women from CEE countries than in women from other geographical origins. Heterosexual women from CEE countries seem to attend GUM services considerably more than heterosexual men from the same regions in spite of high proportions of assortative sexual mixing. Are these heterosexual men from CEE countries attending different services or are they not attending any service at all? MSM from CEE countries seem to be accessing GUM services and reporting high frequencies of unprotected anal sex with casual partners of unknown HIV status. The over-representation of women from CEE countries among the female sex workers attending this specialised clinic is also worrying and calls for further research. As pointed out by Kevin Fenton, new migrant populations need to be rapidly identified through surveillance systems, require collaborative partnerships with the communities and require services that are culturally appropriate to meet new needs.13 These three papers should be used in the design of delivering sexual healthcare to migrants from CEE countries and to improve their access to services.