Abstract
This article is the fifth in a series of articles on sexuality and sexual health.
People's understanding of and needs in sexual health are complex. In recognition of this, fpa—with funding from the Department of Health—published The Handbook of Sexual Health in Primary Care in 2006.a This multi-authored book is written by practising professionals working in sexual health providing evidence-guided and accessible information to support practice. This article is adapted from Chapter 10 and published with permission from fpa.
What is Sexual Health?
When we talk about sexual health, what do we actually mean?
Sexual health encompasses contraception, planning pregnancy, issues around pregnancy choices (including abortion, screening, testing and treatment for sexually transmitted infections) and help with sexual wellbeing. Sexual health services may be delivered ‘under one roof or separately by providers in different settings. Wherever they are provided, the pathways to different sexual health services for consumers need to be clear and seamless. The National Strategy for Sexual Health and HIV 1 sets out a framework for how sexual health services should be provided in England. Similar strategies are available in Wales, Scotland and Northern Ireland. Resources, ‘tool kits’ and standards are available to support and improve sexual health services and care.2-5 These are useful and need to be known about, and, more importantly, used.
WHAT SHOULD WE CALL PEOPLE WHO USE SEXUAL HEALTH SERVICES?
Patients, consumers, users, and clientsare all terms for women and men who receive sexual health services. The reality is that, whatever we call people we see for information, advice, support or treatment, without them we would have no role. There is no universal agreement about the words meant to specify people who use health care. However, people accessing sexual health services are generally ‘well’ people and as such should not be called patients who are seen in the context of ill health. This is not just semantics: how we refer to people in relation to healthcare services affects how we communicate and share knowledge, and has the potential to shift the balance of power between provider and user to one of shared discussion and decision.
Sexual behaviours and attitudes are complex and their outcomes have wide practical implications. People are starting sexual activity earlier, have more sexual partners, use contraception more (but not consistently), and sexually transmitted infections and unplanned pregnancy are increasing. Findings from the National Survey of Attitudes and Lifestyles6-8 illustrate that there is a wide variability in sexual lifestyles by age, gender, relationships and residence—and that this is normal. Research continues to confirm that people do not always behave rationally or in an organized or planned manner with their sex lives, and people do and will take risks intentionally or unintentionally.
Understanding Users’ Views
As part of the NHS Plan to modernize services, public and patient user involvement is now central to service development.9-11 This involves consumers having a central role in how services are designed, developed and delivered in primary and secondary care. Consumer and patient groups, guidance and advice is widely available to support this process.5,12-14
How we consider issues to do with sex—how we talk about it and how we deliver services to support sexual well-being—has enormous impact on how services will be known about and used. Women's and men's sexual health needs, expectations and choices are influenced by many factors: knowledge, information, lifestyle need, age, abilities, sexual orientation, religion, ethnicity, perceptions (their own as well as others’), anxiety and embarrassment. A provider's preferences and assumptions about individuals and service delivery also contribute greatly to limiting or improving acceptability and choice.
What do People want to know about Services?
What services are available? Where are they available? When are they available?
How do I access services? What if I am unable to access them?
Who will I see? Can I choose who to see?
How will I be treated?
Will it be confidential?
What information will I be given?
What choices will I have?
What if I don't understand?
How do I get more information if I need it?
Can I bring anyone with me?
How do I provide comment or feedback on the service I have received?
The helpline and information services provided by
Much of the information we have on people's views of sexual health services relate to young people's views. Their messages are clear and consistent—they relate directly to the need for confidential services that are friendly and non-judgemental.16, 17 Young people's needs ‘mirror’ the views, anxieties and needs of all ages and abilities which
Not wishing to be stereotyped, criticized or judged (‘foolish’, ‘feckless’, ‘promiscuous’, ‘irresponsible’, ‘too young’, ‘should know better’);
Wishing to be treated properly and with respect;
Wishing to be listened to and understood, not interrogated;
Wishing to be given permission to voice fears or anxieties;
Wishing to be empathized with;
Wishing to receive confidential services and know they confidential;
Wishing to be given time;
Wishing to be given more information.
Whilst women are seen more within healthcare services, men are often invisible—yet sex and procreation take two! Sexual-health policies and services do not address men's needs and experiences well. The Men's Health Forum indicates that ‘there is still too little understanding of the impact of gender on men and their sexuality and of the implications this has for tackling men's health problems’. 18 Invisibility also relates to people with disability, who are often seen as not being able to make basic decisions about their sexuality or sexual health. 19 Older people, too, have loving, passionate relationships which include sex, and yet this is often not acknowledged by health professionals. 20
Transcultural, religious and ethnic needs 21 are important to acknowledge and understand, as is the need to remove widespread homophobia and heterosexism that still exists among health professionals. 22 As such, sexual history-taking and questions require sensitive exploration, avoiding assumptions and prejudice. 23
Sexual ill health, such as sexually transmitted infections (STIs) or sexual problems, while enormously common, is still shrouded in stigma and embarrassment. People with worries about STIs repeatedly say that they feel nervous, exposed, vulnerable or scared. This inhibits them from accessing information, help and treatment; often they only use a service when symptoms do not go away and become increasingly intolerable, inexplicable or frightening.
How people access help can be difficult, as UK sexual-health services are currently fragmented—split between general practice, community contraception, sexual health and genitourinary clinics, gynaecology services and pharmacy. This ‘silo’ provision of health services is in direct contrast to the needs of women and men who do not come with isolated problems.
Improving Sexual-Health Service Provision
Service provision
Provide accessible, flexible services that really address the diversity of sexual and reproductive health care needs;
Provide services that are designed, developed and delivered on the basis of needs assessment—involve users, potential users and past users of services;
Provide up-to-date information about all the services you actually offer, so people know about them. Use leaflets, websites, local directories and posters;
Provide information about the sexual-health services you do not provide and give information on how people can access those services;
Find out and really know about other sexual-health services, so you can talk about them from a position of understanding;
Ensure all staff (clinical, medical and non-medical) are appropriately trained, updated and resourced—utilize their different professional skills, strengths and interests to the best advantage;
Ensure confidentiality in visits, communications and record-keeping, and be seen to care about this. You should display a confidentiality poster;
Practice an ethos of equality regarding age, gender, race, sexual orientation and disability;
Ensure that your service policies, practices and attitudes are non-judgemental, friendly and supportive;
Provide, if possible, a choice of female or male doctor, and offer advocacy workers and interpreters where needed;
Ensure that your premises are welcoming, pleasant and accessible for all abilities;
Provide sufficient time—especially for first visits.
Information, support and counselling
Recognize that issues to do with sex can be embarrassing and may cause anxiety both for consumers and professionals;
Always provide appropriate, accessible, evidence-guided information;
Provide ‘back-up’ written information to support verbal advice, possibly in the form of
Always discuss any harm/risk, benefit and uncertainty about any contraceptive method, sexual-health procedure or treatment to support shared decision-making;
Use suitable, up-to-date language that enables and informs, and understand the meaning of value-laden words such as ‘serious’, ‘small’, ‘large’, ‘significant’. Use statistics that can be understood; 24
Be a catalyst and facilitator, not an ‘educator’ who tends to tell people ‘what needs to be done’. Check out information needs by asking questions;
Understand that people need ‘permission’ to ask questions—listen and respond;
Pay attention to discussed side effects of contraceptive methods or treatments—whether real or perceived— as this can say a lot about a person's concerns or needs;
Increase motivation: be prepared to offer solutions to any practical difficulty being experienced.
Footnotes
Competing interests TB was previously the Information Director for