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Barriers to accessing sexual health services

Abstract

Through effective communication school nurses can inform, support and empower young people to make informed choices. Stephanie Enson discusses key barriers to effective sexual health communication and looks at solutions to engage young people.
December 2009 Vol 4 No 10 British Journal of School Nursing 499
Health Promotion
Barriers to accessing
sexual health services
Through effective communication school nurses can inform, support and empower
young people to make informed choices. Stephanie Enson discusses key barriers to
effective sexual health communication and looks at solutions to engage young people.
Communication is an art which like all others
needs to be studied and perfected. However,
health professionals frequently fail to engage
young people prociently, instigating situations where
they believe they have imparted information and young
people have received it, only to have them behave in the
old patterns of putting themselves and their partners at
risk through unsafe sexual practices. Ingham et al (1992)
discussed the discrepancies between young people’s
theoretical knowledge of risks and their actual behaviour
and such ndings illustrate that it is insucient to impart
knowledge alone.
It has become apparent that we are failing young people
in their sexual health needs, given national statistics
illustrating an increasing trend in sexually transmitted
infections (STIs) and unplanned teenage pregnancies
(Health Protection Agency, 2008), . Signicant changes
could be achieved through numerous endeavours
including:
Equipping young people with the right knowledge
Reaching their key internal motivators for change
(aspects of themselves which hold signicant value in
their present day lives to warrant focus and attention)
Providing solid foundations of self-esteem and self-
worth to believe they are worthy of choice, care and
self-preservation in the rst place.
Additionally this must be delivered by open-minded,
unbiased and non-judgmental professionals in a relaxed
and friendly atmosphere. However, it is necessary to
identify the social, political and economic factors that
dictate the norms and values of both the professionals and
young people, as these dynamics contribute directly to
barriers to communication.
Gender imbalance
The UK is still predominantly a patriarchal society. This
applies throughout our social structures, none more so
than within our moral domains. Consequently, we have
‘cast young people as children and have attempted to
shield and protect them from sexual knowledge which
is perceived as corrosive to their innocence’ (Pilcher,
1997: 308). This prevents young people from developing
personal qualities of autonomy and objectivity by
prohibiting them from functioning as adults and equals
in society. In contrast, countries which take a more
open approach towards the sexuality and autonomy
n
n
n
of their young fare much better regarding their sexual
health, with later and lower levels of sexual activity,
more effective protection and much lower conception
rates (West, 1999). Therefore, it appears that social and
cultural approaches to sexual activity in young people
can be a barrier to communication.
e gender power imbalance has contributed to
this confusion and to the mystication of equality for
young people, particularly in relation to young women.
Evans (2008: 2) speaks of sexuality and gender being
intertwined; as one gender exercises a dominant power
over the other (typically male over female) patriarchal
heterosexuality is viewed as the template for all sexual
beings. If gender is socially constructed, typically by
males, this poses a problem for sexual health workers
as the wider implications are that if there is a degree of
repression to young females, they will be lacking a positive
sexual identity, which in turn can prohibit them from
seeking professional help in the rst place. erefore,
gender inequality and socially constructed gender-roles
can be a barrier to communication as it can stop young
people from seeking professional health.
Media influence and the need
for training
Media and celebrity culture, so prevalent and dominant
in modern society, glorifies the ideal being as a young,
healthy, seemingly perfect and, predominantly, a white
person, therefore marginalizing those who do not meet
this ideal (Evans, 2008). Harrison (2000: 67) speaks
of the false construction of media victims, largely to
suit the needs of the fashion world, and argues that
‘self-esteem and self-identity are linked to physical
appearance, especially in adolescence’. The trend
towards instant gratification and high materialistic value
that grips society today only reinforces this negative
imbalance. School nurses themselves are products of
this imbalanced society, which means that they are not
Stephanie Enson is School Nurse, Cambridgeshire
Email: stephanie_enson@hotmail.com
Key words
n Unsafe sexual practices n Positive sexual identity
n Self-actualization n Sexual health assessment
500 British Journal of School Nursing December 2009 Vol 4 No 10
Health Promotion
immune to holding stereotypical beliefs, with inherent
prejudice and stigma (Evans, 2004). This in turn can
impede their communication if not recognized, explored
and addressed through self-development and training.
Crouch (1999: 672) suggests that ‘professional beliefs,
values, and ethics … need to be constantly reviewed’.
Health professionals can be ethically tainted by superior
attitudes of ‘I know best’, ‘abstinence is better’ and ‘do as
I say not as I do’ and Barton and Fox (2000: 216) concur
that ‘health care professionals are [equally] as subject
to their own prejudices’. This can isolate and stigmatize
young people from accessing the very services they
require, therefore preventing effective communication
about sexual health.
We have seen a number of government education
initiatives over the last 10 years including the healthy
schools status programme (Department of Health (DH),
2005), Every Child Matters, and a compulsory sex and
relationship education (SRE) curriculum that aim to
support young people as individuals, improve their life
chances and help them contribute to society as fully
functioning members. However, reluctance has been
demonstrated in some schools to train sta to implement
these strategies and allocate curriculum time, this in turn
acts as a barrier in communicating with young people,
and governing bodies themselves are oen the prime
instigators of such obstruction.
Neglected groups
The gender imbalance that frequently has a negative
effect in our society has a reverse role when it comes to
sexual health provision. Young people’s contraceptive
clinics habitually target young females, adopting what
Evans (2008) describes as ‘a contraceptive mentality’.
This stems from a political system desiring to protect
itself from the negative consequences of unplanned
pregnancies, neglecting young male services to the
detriment of their sexual health and wellbeing. In
schools, sex and relationship education is still ‘too
biologically biased and rarely targets young men’s needs’
(Men’s Health Forum (MHF), 2003: 4). Compounding
this is a historical reluctance on behalf of males to access
health provisions and/or advice until ill health is well-
established (MHF, 2009). Societal influences portray
men as stereotypical ‘macho studswho repress feelings
and have a grin-and-bear-it mentality which fails to
assist men in opening up, expressing worries or anxieties
and accessing the support they need. It is unsurprising
therefore that young male suicide rates are four-to-five
times higher than that of females (Office for National
Statistics, 2009).
Statutory provisions for men hold many shortcomings
that have acted as barriers for young men to communicate
with health professionals and seek services, and there is
a general acceptance that something needs to be done to
improve this. e private sector has made some important
contributions, for example, CALM in the North West
and Brook, have made some positive provisions for men
(e.g. Brook’s advisory service helpline for young men and
young fathers, together with outreach workers tailoring
sexual health information and running sessions that are
designed to meet the needs of young men).
Due to the way in which society is structured and
provision of services made, males are not the only
marginalized group regarding sexual health provision.
Gay, lesbian, bi-sexual and transgender people, ethnic
minorities and the disabled are frequently neglected,
stigmatized and marginalized by health services. Evans
(2001) speaks of the invisibility (within the public image)
of people with physical and/or learning disabilities
having sex, leading to the assumptions that such groups
are asexual. Lesbian women still do not exist in ocial
HIV statistics yet we know some are HIV positive (Oce
for National Statistics, 2006). Provision is oen based
on the results of research and patient surveys (which
may hold hidden aws or agendas) and can result in
such groups appearing invisible or non-existent in areas
of high need and deprivation (Evans, 2008). Research
shows that such groups fall into high risk categories of
sexual ill-health and oen have secondary contributory
factors of low socio-economic class, social exclusion and
family or relationship breakdown rendering them further
at high-risk for sexual infection (Health Protection
Agency (HPA), 2009). Such individuals may oen lack
self-esteem which can make them susceptible to abuse
and exploitation by less scrupulous members of society.
Consequently, this can act as a barrier to accessing
sexual health services and gaining support from
health professionals.
Di Mauro (1995) said:
‘e primary driving force behind sexuality
research in the UK has been a preventive health
agenda that views sexuality as a social problem
and behavioural risk’.
Public health programmes aimed at treating sexual
problems find that STI levels and unintended conceptions
remain high. In contrast according to Warren
(1992: 126):
‘Northern European countries that emphasise
vitality rather than pathology in their public health
approaches experience comparatively low levels of
these negative consequences of sexual behaviour’.
Crouch (1999) talks of creating a more caring and
supportive society through enlightenment, thereby
allowing self-actualization to be realized, something often
sadly missing for our own youth of today. As sexual health
programmes have primarily focused on negatives and
sexual ill-health, this has resulted in instilling fear and
apprehension in young people, both barriers to effective
communication. As a society it is important to learn from
more enlightened approaches which could help alleviate
these barriers.
December 2009 Vol 4 No 10 British Journal of School Nursing 501
Health Promotion
Allowing room for students to talk
Plummer (1995:5) argues that:
‘talking about sex and relationships is central to
contemporary strategies for managing adolescent
sexuality. Talking has become a key element of
identity and self expression central to assertion
of a positive individual if not collective identity’.
Young people require not only the time to talk, but
appropriate space within which they are recognized as
autonomous individuals. Creating the right environment
is of equal importance, the ideal being a relaxed and
informal setting that preserves privacy and confidentiality.
Approachable staff with good listening skills who are non-
judgmental, non-patronizing, helpful and easy to talk to
rate high on young people’s list of priority requirements.
West (1999) draws attention to the necessity for young
people to have sexual health needs integrated with other
important areas in their lives—family and/or relationship
difficulties, bullying and/or peer-pressure, eating disorders
and exam stress, to assist in their development as holistic
human beings. Harrison argues that young people ‘need
opportunities for open discussion about relationship issues’
(Harrison, 2000: 37). School nurses are ideally situated to
assist with this integration process through their drop-in
sessions, one-to-one counselling and outreach clinics.
In providing opportunities to discuss such issues in a
conducive environment we are actively reducing barriers
to communication.
Crouch (1999) conceptualizes sexuality as a very
fragile entity that can be easily aected or damaged by
inappropriate or ill-informed interventions. Practitioners
need to think holistically about all aspects of their role
in sexual health delivery and how these intertwine
with each other. It is apparent therefore that school
nurses need adequate training as skilled communicators
imparting relevant, up-to-date information, correctly
paced and tailored to their client’s individual needs.
Such expertise requires not only continuous professional
development (both pre- and post-registration) as set out
in the Royal College of Nursing’s Sexual Health Strategy
(2001) and the National Strategy for Sexual Health and
HIV (DH, 2001), but continuous individual assessment,
development and reection. Crouch recommends the
use of her Framework for Sexual Health Assessment
(1999) based on the man-living health theory (Parse,
1987), which incorporates a developmental humanistic
approach based on knowledge, cognition, self-awareness
and skills, to assist the practitioner through this process,
and encourage more eective communication between
the client and practitioner.
Equally the school nurse needs to constantly address her
customer care and sexual health assessment process as set
out in Evans’s Sexual Health Skill Competencies (2008) to
ensure delivery of care continues to strive for excellence.
By working within good practice guidance such as that set
out within Evans’s ‘Sexual Health Skills Course’ (2008) and
incorporating tools such as Mitchell and Welling’s (1998)
‘ve keys to good communication’ (i.e. knowledgeability,
attitudes, professional responsibility, comfort and
continued professional education) the practitioner will be
providing the opportunity for relevant positive discourse,
together making a signicant impact on historical barriers
to communication with young people, and oering time
to listen, not merely process.
Improving male sexual health
provision
Mens sexual health needs continue to be neglected not just
by men themselves but by statutory bodies of provision.
Sexual health provision as laid out by Men’s Health Forum
(2003) points to three key objectives urgently needed to
improve men’s health, oering ten points for improvement,
and recommending that the statutory sector needs to
be exible enough to design and market sexual health
services that appeal to young men and are more male-
friendly. School nurses can assist in this endeavour by
ensuring targeted health promotion work with young men
that deals with their concerns, is relevant to their existing
knowledge, is appropriately paced, and in language which
is relevant to them. Topics for discussion may include
penis size, performance, ejaculation and masturbation, as
well as communication and relationship issues and safer
sexual practice. Young men oen report being ‘turned
o by sex education because it too oen focuses on the
biological and scientic aspects and insuciently on the
pleasurable side (West, 1999). If health professionals are to
re-engage young men and improve communication, this
needs to be taken into account.
Society itself may be a victim of the cultures that
constitute it. Psychological models of intervention
have their concepts embedded historically in European
and North American culture. It is only since 1980 that
UK literature has reected the growing concerns and
limitations of these western models when working with
patients from minority ethnic communities (d’Ardenne
and Mahtani (1989). e Feminist movement sparked new
thinking regarding categories of ‘sexuality’ and ‘gender’
(Vance, 1991). Easton et al (2002) said:
‘By tapping into feminist discourse
reconceptualising ‘gender’ and ‘sexuality’ … the
Key Points
Health professionals can hold inherent prejudices and stigma
Historically, society has attempted to shield young people from
sexual knowledge which was thought corrosive to their innocence
Sexuality is a fragile entity which can be damaged by inappropriate
or ill-informed interventions
Young men often find sex education too biological and scientific
rather than pleasurable and enjoyable
n
n
n
n
502 British Journal of School Nursing December 2009 Vol 4 No 10
Health Promotion
Brook
Offers free confidential advice on sex and
contraception for young people
www.brook.org.uk/content/
CALM
The Campaign Against Living Miserably (CALM)
is targeted at young men aged 15–35 years. The
campaign offers help, information and advice via a
phone and web service. Anyone, regardless of age,
gender or geographic location can call the line.
www.thecalmzone.net/default.aspx
Further information
gay rights movement also began to inuence
models of sexuality as well as diversifying
denitions of sexual health’
Despite this, sexual health provision for minorities needs
to increase and improve to include eective methods
of destigmatization. Future research needs to continue
to address why these people disengage, and invisibility
within statistics needs to be eradicated through sound
research and unbiased funding, which will in turn have
a benecial impact on communication. From the school
nurse’s perspective, vigilance around building self-esteem
for these clients needs to be provided, if they are to achieve
optimum sexual health and sexual identity. Evans (2008)
conceptualizes this when he explores the ‘slippery slope
to sexual ill health’ emphasizing the factors of low self-
esteem and poor self-appreciation as creating a craving in
young people for love and aection with an exaggerated
fear of rejection.
Conclusions
Social, cultural and political factors can inhibit effective
communication between health professionals and young
people, and can prevent young people from seeking
professional help regarding sexual health issues. Barriers
related to gender or minority groups can be found within
sexual health service provision and need to be addressed.
Much more needs to be done in terms of listening to young
people, treating them as holistic beings and allowing them
to become autonomous adults. Strategies need to include
creating a welcoming environment and using tools of good
communication to break down historical prejudice and
preconceptions, to reach young people at a level that has
substantial meaning, to achieve effective change in their
sexual practice and to help them reach their optimum
sexual health and sexual identity. BJSN
Conict of interest: None declared
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The Psychology of Sexual Health
  • S Barton
  • P Fox
Barton S, Fox P (2000) Sexual health in primary care. In: Miller D, Green J, eds. The Psychology of Sexual Health. Blackwell Science Ltd, Oxford: 207-19
The National Strategy for Sexual Health and HIV. DH, London Department of Health (2005) National Healthy School Status: A Guide for Schools. DH, London d' Ardenne P, Mahtani A (1989) Transcultural Counselling in Action. Sage, London di Mauro D (1995) Sexuality research in the United States
  • Department
  • Health
Department of Health (2001) The National Strategy for Sexual Health and HIV. DH, London Department of Health (2005) National Healthy School Status: A Guide for Schools. DH, London d' Ardenne P, Mahtani A (1989) Transcultural Counselling in Action. Sage, London di Mauro D (1995) Sexuality research in the United States. In: Bancroft J, ed. Researching Sexual Behaviour, Indiana University Press, Bloomington, IN: 3-8
Sexualities and sexual health/lessons from history. Emergence of sexuality as a sexual health and political issue
  • D E Easton
  • L O'sullivan
  • R G Parker
Easton DE, O'Sullivan L, Parker RG (2002) Sexualities and sexual health/lessons from history. Emergence of sexuality as a sexual health and political issue. In: Miller SD, Green J, eds. The Psychology of Sexual Health. Blackwell Science, Oxford: 53-67
Unit 2: Sexualities and sexual health. Sexual Health Skills Course
  • D T Evans
Evans DT (2008) Unit 2: Sexualities and sexual health. Sexual Health Skills Course [unpublished course material] University of Greenwich Harrison T (2000) Children and Sexuality: Perspectives in Health Care. Baillière Tindall, London Health Protection Agency (2008) Spotlight on infections. www. hpa.org.uk/webw/HPAweb&Page&HPAwebPublication/Page/ 1215072022009?p=1215072022009