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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 HIV1 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.
Patients, consumers, users, and clients are 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 health-care 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.
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 wellbeing—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.
The helpline and information services provided by fpa (The Family Planning Association) handle over 100,000 enquiries annually from the public and professionals. These enquiries illustrate on a daily basis the difficulties that people have in knowing about and accessing good information on sexual health and about services. DIPEx (Database of Personal Experiences of Health and Illness) shows that although there is a wealth of information, it is a maze.15 As such, people are unable to find what they need to know when they need to know it.
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 fpa hears every day through its helpline services. These relate to:
Whilst women are seen more within health-care 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 needs21 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.
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.
Competing interests TB was previously the Information Director for fpa, a national charity dependent on funding to achieve its objectives. This funding is derived from a variety of sources; including commercial companies; however, fpa does not use such funding to produce any consumer information (i.e. leaflets). TB has also received some funding from pharmaceutical companies to attend some international meetings.