Good sexual health – a right for all

For Sexual Health Week 2019, Elana Covshoff blogs about a sexual health service for vulnerable groups – and how the team are in many ways like a modern Call the Midwife.

For many people, sexual health is an uncomfortable topic something not to be discussed in ‘polite’ company, in public and maybe not even in private.

As it’s is Sexual Health Week (and, ahem, 2019) let’s be bold, daring and fearless; let’s talk about sex.  

Seeking support for your sexual health can take courage and patience, and maybe even a half-day off work given the waiting times at walk-in clinics. It can be even tougher for people who face further stigma and prejudice, like people with addictions, serious mental illness, learning disability, sex workers, and the homeless.

I have the privilege of managing a Guy’s and St Thomas’ Charity-funded programme called SHRINE (Sexual and Reproductive Health Rights, Inclusion and Empowerment). The project aims to support those people who find it hardest to access services but whose increased vulnerability and health inequalities mean they need our care and support the most.

These groups experience significant long-term health inequalities – higher prevalence of sexually transmitting infections (STIs)/HIV, unmet contraceptive needs, unintended pregnancies, late recognition and medically complicated pregnancies.

Their marginalisation sometimes means they are more vulnerable to being victims of sexual violence, may take more risks around their sexual behaviour – such as sex working or transactional sex, and often have several co-morbidities. 

Our focus is therefore on those groups who do not use traditional services.

Often the most vulnerable don’t have a GP and in some cases the only contact they have with healthcare services is when they present at A&E. They often negotiate multiple barriers to accessing mainstream clinics, from the very practical issue of not having enough money for transport to anxiety around being asked their history with drugs, mental health, social services, or wanting to avoid talking about traumatic personal experiences. Past experience can sometimes make marginalised groups distrust “the system”..

As a specific, practical example of the challenged faced by one of our target groups - the logistics of seeing a person with serious mental illness at a sexual health clinic can be very difficult.

Psychiatric inpatients may only be allowed 30 minutes leave from their ward. Sometimes this can be extended to an hour, but it is still very unlikely they will get through the long waiting times seen at many walk-in clinics. They also often have to be escorted in case there is an absconsion risk. Yet there is not always capacity within a mental health team to escort patient to our clinics, sit and wait to be seen, and then travel back.

Meanwhile, sexual health services often operate a zero-tolerance approach towards unusual behaviour and may not realise the person’s behaviour is due to a mental health condition rather than being ‘difficult’ or ‘disruptive’.

SHRINE works creatively and flexibly to reach patients who often live chaotic lives and require complex care. Rather than expecting these patients to come to us at our clinics, we go to them.

We offer: an assertive outreach and inreach service where a doctor, with a supplies backpack, attends addictions centres, inpatient psychiatric wards, homeless hostels, and can make the occasional home visit with a social/key worker. And we do this by bicycle. Think ‘Call the Midwife’ but delivering contraception and STI or HIV care instead of babies.

We also encourage people to come to our clinics so they get familiar with  us and feel more comfortable. Our patients receive a booked appointment, and generally come with a social/key worker/mental health professional they know and trust.

SHRINE empowers our patients to plan and space pregnancies, treat STIs/HIV and help marginalised people to enjoy a safer and healthier sex life.

Sadly, under current funding arrangements SHRINE is barely able to meet some 10% of the demand for our services.

But, building capacity to care for more marginalised people will have a significant and beneficial effect on their lives and reduce health inequalities. Our work will also reduce societal costs across the health and social care economy, eg from A&E, maternity, addictions, mental health and social care etc.

So, what may initially sound like a niche and specialised intervention could certainly bring much wider benefits as we increasingly place prevention at the heart of healthcare.

Acknowledgements and further information

SHRINE is a team providing sexual and reproductive healthcare (SRH), as well as expertise in addictions, psychiatric, intellectual disability and human-rights. We improve the availability, access, acceptability and quality of SRH care. We are:

  • Dr Rudiger Pittrof, Consultant in Community Sexual Health and HIV, Guy’s and St Thomas NHS Foundation Trust
  • Dr Usha Kumar, Consultant in Sexual and Reproductive Health (Kings College Hospital NHS Foundation Trust
  • Elana Covshoff, SHRINE Programme Manager and Human Rights Specialist
  • Dr Shubulade Smith, Consultant in Psychiatry, South London and Maudsley NHS Foundation Trust
  • Rosie Mundt-Leach, Head of Nursing, Addictions Clinical Academic Group, South London and Maudsley NHS Foundation Trust
  • Alan Schofield, Rights Holder and Patient Expert
  • Sue Mann, Head of Evaluation, Medical Expert and Public Health Consultant in Reproductive Health

Find out more about the SHRINE project.

King’s Health Partners Mind & Body is committed to joining up mental and physical healthcare, training and research to improve health outcomes for our patients and service users.