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If you are a woman with lived experience of selling/exchanging sex or images online, you can anonymously make your voice heard on your sexual health needs and your experiences of sexual health care during the coronavirus pandemic by completing our sexual health survey
SEXUAL HEALTH & WELLBEING
We've arranged our show notes into easy-to-read sections. Please click to expand:
THE IMPACT OF THE CORONAVIRUS PANDEMIC ON WOMEN’S SEXUAL HEALTH AND WELLBEING
Having access to appropriate and effective sexual health support is so important to our overall wellbeing – allowing us to access routine services like contraception and STI testing and treatment but also time sensitive services abortion services, HIV treatment, and support with rape and sexual assault. Sexual health services can also provide a space for us to discuss our sexual wellbeing in a holistic way, allowing us to talk through our feelings, emotions, and relationships with trained, non-judgemental staff. For some women who sell or exchange sex, sexual health services may be the only support service they are regularly tapped into with specialist services in Glasgow (Sandyford G3 Priority Clinic) and Edinburgh (WISHES Clinic) acting as key support hubs helping women to access vital health services such as routine STI testing and contraception but also sign-posting women into other areas of support, such as housing and benefits advice.
However, the coronavirus pandemic has significantly impacted the way sexual health care in Scotland can be delivered. Many sexual health services – including specialist services – had to reduce face-to-face appointments and prioritise those with the most urgent sexual health needs. In some areas of Scotland, sexual health clinics were closed, and staff moved to other areas of the NHS to support the initial response to coronavirus. Where sexual health clinics did remain open, some people were worried about accessing services due to potential exposure to coronavirus. As a result, women’s access to sexual health care was severely impacted. Heather Cumberland, Community Engagement Lead at HIV Scotland had this to say:
“It could be seen very quickly […] that people were, by both services closing but also by people not wanting to access services in case they put themselves at risk, that they weren’t able to access contraception, condoms and testing […] I think there was a study that showed that people buying contraception online was up by 35% in the UK…but that’s the people who can afford to pay for their contraception there is many people who can’t do that. That comes into things like the morning after pill., being able to avoid unwanted pregnancies. [It also affects] access to things like PEP* (Post exposure prophylaxis) [for people who are more at risk of HIV] people didn’t have access to that and so they’re more at risk of contracting HIV. I think that definitely applies to women who sell sex, not being able to access things such as PEP or being able to go onto PrEP* (Pre exposure prophylaxis) […] that service actually in Scotland closed, so there was nobody able to go onto PrEP during the pandemic”
* It’s important to note that prescription of both PEP and PrEP is based on an assessment of an individual’s level of risk of contracting HIV. Being involved in selling or exchanging sex does not make a woman automatically eligible for PEP or PrEP. You can find out more about PEP and PrEP at HIV Scotland
WOMEN’S SEXUAL HEALTH NEEDS DURING THE PANDEMIC
Many women involved in selling or exchanging sex have had no option but to continue seeing clients face-to-face throughout the pandemic. As a result, having access to safe, secure, and confidential sexual health care which meets women’s rights and needs have never been more crucial. However, sexual health services have not been able to operate as normal. Dr Alison Scott, a consultant gynaecologist with the WISHES clinic in Edinburgh had this to say:
“Initially in lockdown we were almost completely shut down aside from urgent cases. We then moved to trying to see vulnerable women but it’s very difficult. It was kind of ‘well we’re sitting here waiting for people to walk in the door’. […] We’ve been very constrained in what services we’re able to offer. We now have reopened WISHES and that’s now working but there’s restrictions on how many women we can see […] A lot of our staff were pulled onto covid testing, some of them have come back but they’re now being pulled onto contact tracing […] so we are short staffed. Many areas of the country had their premises taken over for other services to use. Grampian, for example, had no premises for a very long time. It’s had a devastating impact on the delivery of services…and it’s difficult to get them back to where they were before”
At the moment, phone and video consultations are being used to determine whether a face-to-face appointment would be appropriate or required. Whilst some women are happy with these consultations, as they are flexible and can fit into their day-to-day lives, others are not able to benefit from phone or video consultations due to being digitally excluded. Other women report not feeling comfortable with phone and video consultations due to privacy concerns and worries about talking about their sexual wellbeing in their home environment where other people may overhear. Women have let us know via our RISE Sexual Health survey that they had had a positive experience of accessing sexual health services prior to the pandemic. Women reported feeling comfortable disclosing to staff that they were involved in selling sex and were happy receiving regular check-ups and condoms from these services. However, women state that their access to sexual health care has got worse during the pandemic. One woman said:
“There have been no services that I have been able to get during the pandemic which means I have missed my more regular checks. I got condoms via post from another service. Women's services have tried to meet the need of women working in the pandemic, but NHS services have been closed so testing etc has not been available”
Crucially, the coronavirus public health messaging – to stay at home, keep your distance from others, and not mix with people out with your household – may also be acting as a barrier to women accessing sexual health services during the pandemic. Although this messaging is based in science and is important to follow in order to keep ourselves and our communities safe and well, the messaging is fundamentally incompatible with the reality of the lives of many women involved in selling or exchanging sex who have had no choice but to continue to see clients face-to-face. As a result, this messaging has resulted in increased anxiety among women and increased fears of potentially being criminalised for not abiding by the guidance when they have had no other option in order to survive. Emma Thompson, a specialist sexual health nurse at the Sandyford G3 Priority Clinic had this to say:
“So, I think from what I have heard from women, I think there has been fear of disclosure of transactional sex. I think there’s been fear of whether there will be any consequences or repercussions as the guidance says we shouldn’t be having sex with people that we don’t live with. I really hope it hasn’t stopped anyone coming into G3, that’s my hope, but I think in reality it perhaps has. They may associate NHS with coronavirus, with test and protect, and would there be any kind of communication [with test and protect]? Which there wouldn’t be, absolutely not, data protection and confidentiality stands – coronavirus doesn’t change that. But I think there will be, naturally, some fears around that”
Sexual health is holistic. Our sexual health is not just related to our reproductive organs but is linked to, and affected by, our overall wellbeing. Since the beginning of the pandemic and throughout, women have been letting us know that their most urgent need is money. Women’s sexual health and wellbeing can be impacted by financial instability. Difficulties in paying bills and making rent, for example, may place pressure on a woman to offer services that she is not entirely comfortable with in order to make more money. For example, we have heard from women that there has been an increase in clients requesting bareback – sex without a condom – which can put women’s sexual health at risk of STIs and blood borne viruses. Although financial support has been available to women via funds like the Encompass Fund and Victim Fund, as well as Umbrella Lane’s emergency fund, these financial supports have all been short-term and are not resourced to significantly support women’s financial wellbeing as the pandemic continues. Dr Alison Scott and Emma Thompson both note that financial worries are a key concern that women have been raising at their sexual health appointments throughout the pandemic, with Alison noting:
“I think [the coronavirus pandemic] has shone a great big light on the issues around deprivation because those affected by deprivation have been most affected by covid from the point of view of risk of disease but also loss of income and difficulties accessing services. Women are now coming to the clinic and saying that they are having lots of sex because they are trying to bank lots of money in case we go into lockdown again and they lose their income again. So, they’re now working extremely hard, exhausting themselves, putting themselves at risk, because they’re frightened that we’ll go back into lockdown and they’ll be left with nothing again”
Our sexual health can also impact other areas of our lives. A lack of access to routine STI testing is also having an impact on women’s mental wellbeing. Heather Cumberland from HIV Scotland notes:
“Sexual health does have a big impact on mental health. We’ve had a lot of people contacting us with general sexual health concerns that are affecting their mental health during the pandemic because they don’t have a place to turn to. To have that holistic view of, actually, these things all relate to one another has really come up during this time where we can see there’s a definite lack of women’s voices when it comes to sexual health services and a lack of a holistic approach to our general wellbeing”
Whilst the pandemic has had a significant impact on how sexual health services can be delivered across Scotland, it is important to highlight that women were already facing barriers to accessing sexual health care prior to the pandemic – some of which have been amplified and compounded by the pandemic. Women involved in selling or exchanging sex can experience a great deal of stigma when accessing healthcare which can prevent the quality of care a woman receives and the likelihood that she will engage with services in the future. For some women who sell or exchange sex and use substances, they report experiencing dual stigma. Adrienne Hannah the training lead at Scottish Drugs Forum notes:
“Certainly, if we’re talking about women who use drugs and who sell or exchange sex, we know that they’re not getting routine sexual health check-ups. We know that they’re not accessing contraception, they’re not using condoms, they’re not getting STI and blood borne virus checks. Part of that is about stigma, real or perceived stigma. If their experience in the past has been that they’re not treated equally by services, they’re unlikely in the future to use that service […] So, for example, if you’ve arrived at a sexual health service and you’re a bit out of your face and you’re asked to wait outside rather than in the waiting room – what are the chances of you ever coming back to that sexual health service again? No matter how good it ends up being”
Women also face geographical barriers in accessing sexual health care. There are specialist sexual clinics in Glasgow (Sandyford G3 Priority Clinic) and Edinburgh (WISHES Clinic), however, in rural areas access to even a general sexual health service can be limited. At CLiCK, we have heard of some women having to travel large distances for both general and specialist sexual health care.
WHAT IS BEING DONE TO MEET WOMEN’S SEXUAL HEALTH NEEDS?
Sexual health services, and third sector services, in Scotland have worked hard to be adaptive and flexible to ensure women involved in selling or exchanging sex have access to high quality sexual health care during the pandemic.
At home testing
Many sexual health clinics were able to post out routine STI testing kits to people who did not require a face-to-face appointment. Importantly, this provided women with more options in accessing sexual health care and freed up sexual health staff for individuals who would benefit most from face-to-face to appointments. HIV Scotland also formed a partnership with Waverley Care to provide at home testing for HIV – of the approximately 2000 people who have given demographic information when accessing a test, 25% were women with the main reason for accessing tests being unprotected sex
Condoms by post
Services like CLiCK and Umbrella Lane were able to provide condoms and lubricant via the post throughout the pandemic
The WISHES clinic provided telephone outreach during lockdown, checking in with women on a weekly to monthly basis to see how they were doing. During the pandemic, some NHS boards also provided outreach by taking abortion medication to women. Women’s workers in Encompass Network services continued to meet women’s various needs on a local level during the pandemic by dropping off food parcels, sanitary products, toiletries, and condoms to women
Now that the WISHES clinic is reopen, they are continuing to meet women’s needs through helping women access advice around various needs such as benefits and housing and providing free toiletries, sanitary products, and food
The inclusion team at Sandyford Glasgow, which Emma Thompson is a part of, were ring-fenced. This means that the service was not repurposed to support the initial coronavirus response and staff were not reallocated to other areas of the NHS. Emma notes that this decision was vital as it meant the team were available to support people who had experienced abuse and domestic violence during the pandemic
WHAT NEEDS TO CHANGE?
At the start of the pandemic, the World Health Organisation published interim guidance to support countries in keeping sexual and reproductive health services open as essential services. However, this guidance has not been heeded everywhere. There is a need to ensure that women’s sexual health and wellbeing is treated as a priority to prevent worsening existing health inequalities. Given that we know sexual health services are sometimes the only service that women who sell or exchange sex are regularly tapped into, it is clear just how important these services are in “normal” times and even more so during a pandemic.
Valuing women’s lived experience is crucial to ensuring that sexual health services work for women who sell or exchange sex. Women need to not only be listened to but be actively included in any service change or development that will affect their lives, and services must clearly demonstrate how women’s feedback will be taken on board. One woman who responded to our RISE survey provided a list of the things she thinks need to change to improve sexual health services for women who sell or exchange sex:
“Easy access clinic to go and get tested as this is important. Some women don't feel comfortable going to a GP so a specific service only for women would be better. A specific service for women who sell / exchange sex. Would not mind of this was staffed by male or female health professionals. A non-judgemental attitude about the work we do. To be knowledgeable and experienced in giving support if positive results for STI's etc are given.”
Importantly, accessibility of specialist services is a core part of the Women’s Health Plan which is currently being drafted by the Scottish Government’s Women’s Health Group. The aim of this plan is to improve the accessibility of services and address health inequalities by taking sexual health care to women. At the same time, Healthcare Improvement Scotland are updating the standards for sexual health care to align with an outreach model. Both bodies of work will be shaped by a lived experience group which will be inclusive of the voices of women involved in selling or exchanging sex. Dr Alison Scott, who is a member of the Women’s Health Group, had this to say about these areas of work:
“Hopefully, when the Women’s Health Plan is published and implemented…the whole model of delivery of sexual health care will change. And rather than sitting in a building and saying ‘well, we’re open 9 till 5 you’re very welcome to make an appointment to come and see us’ that will move away and we will be sending staff to places where women are going for childcare, for employment, for substance misuse issues. Being a bit more creative. Taking the care and expertise to groups where women are and then we can talk to them and signpost them to what is appropriate according to their needs. The HIS are about to rewrite the sexual health standards and hopefully they’ll sit alongside the Women’s Health Plan in reflecting a slightly different model with more focus on outreach and making sure services are accessible”
Adrienne Hannah notes the importance of continued sharing of knowledge and learning between sexual health and drug services to challenge the dual stigma and discrimination that women who sell or exchange sex and use substances face. Adrienne also states that women must be empowered in discussions around their sexual health and must be presented with all options available to them – particularly around contraception and family planning – and that sexual health staff should not make assumptions about women’s sexual health wants and needs.