Available via license: CC BY-NC-ND 4.0
Content may be subject to copyright.
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=tchs20
Culture, Health & Sexuality
An International Journal for Research, Intervention and Care
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tchs20
Photodiagnosis of genital herpes and warts: a
sociomaterial perspective on users’ experiences of
online sexual health care
Paula Baraitser & Deborah Lupton
To cite this article: Paula Baraitser & Deborah Lupton (2022): Photodiagnosis of genital herpes
and warts: a sociomaterial perspective on users’ experiences of online sexual health care, Culture,
Health & Sexuality, DOI: 10.1080/13691058.2022.2031297
To link to this article: https://doi.org/10.1080/13691058.2022.2031297
© 2022 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group
View supplementary material
Published online: 17 Feb 2022.
Submit your article to this journal
Article views: 602
View related articles
View Crossmark data
Photodiagnosis of genital herpes and warts: a
sociomaterial perspective on users’experiences of online
sexual health care
Paula Baraitser
a
and Deborah Lupton
b
a
SH:24, London, UK;
b
Centre for Social Research in Health and Social Policy Research Centre,
Vitalities Lab, UNSW Sydney, Sydney, Australia
ABSTRACT
Online sexual health services potentially transform modes of
engagement with service users. We report findings from an in-
depth interview study with users of a photo-diagnosis service
offered by an established UK-based online sexual health service
(SH:24). Adopting a sociomaterial theoretical perspective, we ana-
lyse the interviews for descriptions of health care with and
through the affordances offered by SH:24. We focus on how the
interactions of service users and clinicians with nonhuman agents
opened or closed off capacities for better health and wellbeing.
Our findings explore navigating online and in-person service
options; digitising bodies; temporal affordances; the tension
between anonymous and personalised care; configuring digital
privacy; and when automated care is not enough. We conclude
that emerging practices of care within digital health services
delivered by more-than-human collaborations reconfigure experi-
ences of diagnosis and treatment and require detailed attention
to understand how they create and close down opportunities to
improve or maintain health.
ARTICLE HISTORY
Received 27 April 2021
Accepted 15 January 2022
KEYWORDS
Digital health; sociomaterial
perspective; sexual health
Introduction
Digital technologies have become increasingly important for health service delivery,
including sexual health care, testing and treatment. Such technologies can expand
access to services (Wilson et al. 2017) and to peer support and information (Courtenay
and Baraitser 2021), including for vulnerable or hard-to-reach populations and social
groups (Nanda and Tandon 2019). The COVID-19 pandemic has limited in-person sex-
ual health care and accelerated development of online services (Church, Gassner, and
Elliott 2020). However, online health care has also generated new concerns about
inequalities in digital access, maintaining the privacy of sensitive information that is
CONTACT Paula Baraitser paula@sh24.org.uk
Supplemental data for this article is available online at https://doi.org/10.1080/13691058.2022.2031297.
ß2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in
any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
CULTURE, HEALTH & SEXUALITY
https://doi.org/10.1080/13691058.2022.2031297
uploaded and stored as part of service use, and the erosion of care within therapeutic
relationships (Mol 2008; Ippoliti and L’Engle 2017; Newman et al. 2020). It remains
unclear to what extent digital services could or should seek to re-create familiar ways
of therapeutic caring.
As part of a process of re-thinking the value of different media for health service
delivery, we report findings from an in-depth interview study with users of the photo-
diagnosis process offered by SH:24, an online sexual health service ("SH:24" 2021).
Established in 2014, SH:24 is a not-for-profit organisation commissioned by the public
sector in the UK. The service provides 24/7 free and confidential diagnosis and man-
agement of sexually transmitted infections (STIs) and online contraceptive services
with support from specialist sexual health clinicians. SH:24 was co-designed with
healthcare consumers and providers through an iterative process using a model devel-
oped by the UK Design Council (The Design Council 2015; Trimble 2016). The service
has received awards for design and user experience
1
. It is designed to be attractive
and simple to navigate, and to communicate both accessibility and anonymity.
SH:24 service users provide personal information via an online form, with test kits
for self-collection of blood or urine sent by post in discreet packaging and returned to
the service for analysis. People with symptoms of genital herpes and genital warts can
access the photo-diagnosis service, where they upload self-taken photographs of their
lesions to be assessed by specialist clinicians. Where required, treatment is prescribed
and posted to users through a UK-based registered pharmacy with remote specialist
clinical support provided through text/phone. If a diagnosis cannot be made, or if clin-
ically indicated, users are referred to in-person clinical care.
The interviews reported on here were conducted by SH:24 as part of an evaluation
of user experience. For the purposes of this paper, we have re-analysed the interview
transcripts from a sociomaterial perspective, with attention to surfacing the details of
how users came together with clinicians, the affordances of the platform, and other
material dimensions when seeking diagnosis and treatment. We focused on a particu-
larly sensitive area of health care: namely, the digitised diagnosis and management of
genital herpes and genital warts. Both infections mainly cause mild disease yet are
experienced as highly stigmatising (BASHH. 2014) and cause significant short- and
long-term emotional and psychosocial consequences, including anxiety about telling
current and future sexual partners (Mortensen and Larsen 2010; BASHH. 2014). Both
infections are common, with 5% of the world’s population experiencing genital ulcers
from herpes infections each year (Looker et al. 2020) and 4% of the UK population
reporting a previous diagnosis of genital warts (Sonnenberg et al. 2019). The mainstay
of diagnosis for herpes and warts is a visual assessment of the genital lesions
(although tests are also important in the diagnosis of herpes) with self-managed treat-
ment options available making diagnosis and treatment possible within a digital
health service. Genital herpes and warts account together for 18% if all new diagnoses
of STIs in England (Public Health England 2020) and moving management of these
conditions online could potentially improve access as well as reduce health care costs.
The shift online in healthcare has been typically framed in terms of efficiency and
convenience but much less in terms of care. Yet caring is a fundamental element of
health services. For example, the UK regulator responsible for monitoring, assessing
2 P. BARAITSER AND D. LUPTON
and rating health services, the Care Quality Commission, includes caring (treatment
with compassion, kindness, dignity and respect) as one of five key areas of health ser-
vice assessment (CQC (Care Quality Commission) 2021). A lack of attention to care
within digitised health services is an omission with implications for both clinical safety
and service user experience which we hope to address in our study.
Background
Our approach to understanding service users’experiences with SH:24 adopts a socio-
material perspective which recognises that people’s encounters with digital platforms
are dynamic assemblages of humans and nonhumans. In our work, we draw on
foundational scholarship in more-than-human theory offered by Indigenous and other
non-western philosophy (Gibson 2019; Hern
andez et al. 2020) and feminist new
materialism (Bennett 2010; Puig de la Bellacasa 2017). Adopting this approach, states
of health and ill-health are understood as continually configured and reconfigured as
humans come together and come apart with other people, other living things and
with non-living things, place and space. Health states are positioned as always lively
and relational, generated with and through people’s interactions with other agents,
including other people but also nonhuman agents. From this perspective, the task of
social analysis is to untangle complex assemblages and understand how diverse
agents and relational connections influence states of good health and wellbeing
(Andrews and Duff 2019; Crath, Gaubinger, and Rangel 2019; Lupton 2019).
This theoretical approach and research focus includes addressing how humans and
nonhumans come together in matters of care (Lupton and Maslen 2017; Puig de la
Bellacasa 2017). Understanding everyday practices of care in health settings is import-
ant to ensure that these practices are attended to and not eroded (Mol 2008). When
health care is offered ‘at a distance’(Pols 2012) via digital platforms, devices and apps,
a more-than-human perspective directs attention to the ways these technologies and
other objects entangle with human bodies in generating affective forces and relational
connections that can work to open or close off agencies to achieve wellbeing and
good health (Lupton 2019).
Previous research adopting a sociomaterial perspective has shown that care within
digital health services makes some familiar strategies more difficult, as the multi-
sensory elements of in-person diagnosis and treatment are limited (Lupton and
Maslen 2017). The reduction of health care to visual and often text-based communica-
tion, and particularly the loss of haptic and contextual elements of care, may generate
a sense of ‘disengaged distances’(Puig de la Bellacasa 2017) that might not support
therapeutic relationships. However, the affordances of digital services, or the features
they are designed to offer users (Davis and Chouinard 2016), also make new types of
diagnosis, treatment and caring relations possible. Digital health services can transform
the modes, time and space of interactions (Nicolini 2011). Communication often
changes from synchronous to asynchronous, from face-to-face to digital and from
voice-based to text-based. These shifts in the delivery of healthcare bring new options
for caring, such as more regular ‘checking from a distance’(Pols 2012) where provid-
ing permission to communicate regularly and a way of doing this that is less intrusive
can generate a feeling of being protected and reassured (Piras and Miele 2019).
CULTURE, HEALTH & SEXUALITY 3
Done well, care at a distance can feel ‘warm’, friendly and supportive –helping people
feel that someone is checking on them and is concerned for their wellbeing, even when
thereisnodirecthumancontactinvolved(Pols2012). For example, a study of automated
textmessagesforpeoplewhoaretryingtogiveupsmokingfoundthatthemessageswere
experienced as a ‘friend batting in your corner’(Douglas and Free 2013). In this example, the
interface ensured that messages were delivered regularly, reliably and responsively at the
times and in the manner chosen by the recipient. Similarly, ‘digital intimacy’can be achieved
where digital technologies provide a great quantity of regular clinical measurements more
frequently between providers and service users (Piras and Miele 2019). In this context,
remote digitised care can offer closer monitoring of complex health conditions, bringing pos-
sibilities of both enhanced health care and enhanced surveillance.
Most qualitative studies related people’s use of digitised sexual and reproductive health
services have focused on digital devices designed for monitoring aspects of sexual activity,
pregnancy, menstruation and fertility (for example, Lupton 2015;Wilkinson,Roberts,and
Mort 2015; Karlsson 2019;Grenfelletal.2021). This research shows that users appreciate
such benefits as feeling in better control of their bodies, being able to predict fertility cycles
and prevent or achieve pregnancy. However, these technologies often overly focus on indi-
vidual responsibility for good health, adopt a highly normative gendered approach and mar-
ginalise or ignore users who do not identify as cis-gendered or heterosexual or who are
living with disabilities or on a low income. The use of these devices and apps can also require
invisible labour that can become overwhelming to users. Women are particularly expected
to conform to expectations to be responsible digitised reproductive citizens, carefully man-
aging their bodies in terms of sexual and reproductive health and functioning.
Less social research has been conducted on topics such as the affective and
relational elements of digitised services for sexually transmissible infections. One
exception is a project involving a more-than-human analysis of the use of an HIV self-
testing app (Janssen et al. 2021) which documents the affective elements of testing as
mediated by this technology.
Our study builds on this work by focusing on a photo-diagnosis service and surfac-
ing the relational connections and affective forces that together opened or closed
agential capacities for service users. In the case of SH:24, people are engaging with
other people via the affordances of the platform, which itself was designed by people
with the needs of both clinicians and users in mind. The service users’bodies are digi-
tised in various ways, including through the digital images they take using their smart-
phones and send to the service providers for examination and through text messages
exchanged with the providers. Humans come together with technologies at each
stage of the process to configure capacities, including the provision (or non-provision)
of a diagnosis. These capacities are structured and delimited with and through the
design of the platform: beginning with how users first engage with SH:24 clinicians by
making initial contact and seeking help or advice for their health problem.
Materials and methods
We re-analysed qualitative data from ten semi-structured interviews conducted by two
different researchers, Jessica Engen and Alan Black, as part of an evaluation of the
4 P. BARAITSER AND D. LUPTON
acceptability of the online photo-diagnosis service. Ethical approval for the study was
provided by London Fulham NHS Research Ethics Committee (Reference 18/LO/2007).
Users of SH:24’s photo-diagnosis service during the study period were invited to take
part via an SMS sent by the researchers and purposive sampling was used to ensure
variability in terms of participants concerns (warts or herpes) and clinical outcomes
(treated, referred or reassured).
There were 268 eligible users during the study period, of which 139 were invited to
interview, and 27 agreed to be interviewed. Of the ten people who completed an
interview, seven were conducted in person and nine identified as female. A maximum
of two follow-up texts were sent to non-responders. Informed consent was obtained
prior to the interview. Face-to-face interviews took place in a private room at
a university.
Prior to commencing the telephone interviews, the interviewer confirmed that par-
ticipants were in a suitable location where they felt comfortable. All participants were
offered a £30 gift voucher for a face-to-face interview (to allow for travel time and
costs) and £20 for a telephone interview. Interviews were audio recorded and tran-
scribed verbatim and all participants were given an identifying number to maintain
their anonymity. Of the ten participants, all described their gender as female, six were
aged 20–29, three were aged 30–39 and one 40–49 years. Three described themselves
as White British, one as Black Caribbean, one as Black African, one as Black Other and
one as mixed White and Asian. Four were concerned about genital warts and six
about herpes.
Our theory-driven approach to analysis focused on the issues generated from our
reading of the literature on health care in digital settings reviewed above: specifically,
more-than-human assemblages of care and their influence on affective and relational
dimensions of service user experience. Following the analytical method outlined in
previous analyses of digital health use adopting this approach (see, for example,
Lupton 2019; Janssen et al. 2021), we read through the transcripts looking for ways in
which the participants described their experiences of the photo-diagnosis service in
terms that referred to affective states and relational connections made between the
humans and nonhuman agents involved (both digital and non-digital, and including
place and space), and the ways in which interactions in these assemblages opened or
closed agential capacities. Our findings are grouped under the following main themes:
navigating online and in-person service options; digitising bodies; temporal affordan-
ces; the tension between anonymous and personalised care; configuring digital priv-
acy; and when automated care is not enough.
Findings
2
Navigating online and in-person service options
The accounts of service use showed that most participants used multiple services and
platforms, both in-person and online, within a single episode of care with many frus-
trations and dead ends. A typical journey of service use started with a concern about
a symptom that triggered an online search and a subsequent attempt to book an
appointment at a family doctor or specialist health service. Those people who visited
CULTURE, HEALTH & SEXUALITY 5
family doctors were referred to specialist health services and members of this group,
as well as those who went directly to sexual health services, struggled to obtain access
to specialist clinics because of long waiting times or limited availability of appoint-
ments and tried the digital service instead. They sought many different outcomes
including, a diagnosis, treatment, reassurance or information. These accounts sug-
gested that interviewees at first had wanted face-to-face care and that seeking care
from SH:24 was the endpoint rather than a starting point. As participant 5
described it:
There was lots of Googling and trying to work out what [the condition] was. Then I
actually had my smear test coming up so I thought I could get that checked at the same
time, but I was told that I had to go to, like, a specialist sexual health clinic or person. So,
then I started researching how to do that and I had used SH:24 before so I thought
maybe there would be a service and there was …I would have liked to have gone to a
clinic, but it just didn’t fit in with my schedule and I was trying to also call various clinics
and I couldn’t get through as well.
Previous experiences with face-to-face services were often reference points for
descriptions of online care. People compared the two, noting the differences and pros
and cons of each, including the feelings and relational connections that are generated
as they encounter humans (often health care professionals) and nonhumans (appoint-
ment booking systems, online information systems) when seeking a diagnosis. For par-
ticipant 1, the clinic was ‘more intimate’and the online service provided ‘a quick fix’.
Finally went to clinic and got treatment –I felt a bit better, but I think maybe because
they took up the time, I spoke about the situation, I think I was there for best part of an
hour actually, talking about different symptoms and everything like that. I think he was
like a specialist. And I felt listened to and then obviously I had the whole sexual health
screening as well at that moment for that time as well. And everything else was alright.
So by the time I left there, I actually felt pretty better, like liberated, like, ‘Okay, I’ve got
this under control now’.……… The strength of the online, I saw it as kind of like a
quick-fix, take the pictures, upload, you kind of forget the medication, the medication is
sent to you. Whereas I find that, with the face-to-face service, it’s more intimate.
Digitising bodies
Interactions with nonhumans were present in users’accounts of their experiences of
taking photographs of their genitals and sending them to the SH:24 platform. The
quality of images facilitates the diagnosis process, which was conducted by the SH:24
medical staff who examined the photographs rather than conducting a clinical exam-
ination in person.
The platform provides instructions on the images required and how to take them,
including positioning a penny coin near lesions to provide scale. In the interviews,
agents such as text messages, smartphone cameras and flash capabilities, the space
and place in which the images were taken, phones, the coin, the information provided
on how to take the photograph and the interface for uploading images were men-
tioned as contributing to the interactions involved in configuring a diagnosis. The
need to take and review the photographs required people to interact closely with
their own bodies. This a different situation compared with a clinical setting, where
6 P. BARAITSER AND D. LUPTON
once a user has identified a lesion of concern there is the option to delegate close
examination to the clinician.
All these elements generated strong affective forces and relational connections as
users negotiated the quality of the camera on their phone, their ability to use it effect-
ively, the space and place in which they were taking the photograph, the need to
place the coin correctly and the position of the lesions. As participant 5 put it:
SH:24 is the one that asked for a coin, is it? I found like that was, that’s kind of like an
impossible step. I think I actually gave up on that in the end …I don’t know how to
take a better picture, really, because even for my own records, to be honest, just check
what was happening …Well, you’ve got to hold a phone, potentially a light source. And
a coin that’s kind of, and at an angle. So, yes, I just don’t think I had enough hands for it
…And I guess also when, on my phone anyway, when you get too close it won’t focus.
So, that’s why it was getting blurry.
Humans working together with the affordances of nonhuman agents in generating
images resulted in both opening capacities for diagnosis but also closing them. Depending
on the smartphone, lighting and the skills of the person taking the images, as well as their
ability to manipulate their body to obtain a clear sight of their genitals, image quality was
variable. The photographs taken sometimes offered a different view of the lesions from that
offered by direct visual inspection: for example, if the image was very magnified. They also
sometimes changed the colour and definition of lesions. These visual dimensions sometimes
facilitated diagnosis but at other times did not. As participant 5 commented, the SH:24 clin-
ician responded that they could not make a diagnosis from the photograph uploaded: ‘Well,
it was kind of, we can’t diagnose it …they also thought that it looked really red, which I
think was actually my photo and not what real life’.
Temporal affordances
Compared to in-person health care encounters, once an interaction is initiated by a
service user (by accessing the platform and completing the online form), SH:24
spreads the timing of care over a longer period of time. For example, once a photo-
graph has been successfully uploaded, the user is immediately reassured that it has
been received, even if it is late in the evening. This affordance relies on messages writ-
ten by humans at the time of service development and delivered by the system when
the image is uploaded. This shows care, in understanding and pre-empting possible
concerns about the safe receipt of their photographs. Further communication may be
spread over time as users and clinicians ask and answer questions by text message, so
interactions are not confined to the time frame of a clinic appointment. These are
unfamiliar options and users had to learn to experiment with these affordances
offered by the platform for continuing follow-ups:
(They messaged) ‘How far are you getting along?’and stuff like that. And I think it was a
good prompt for me to say, ‘Actually, yes, I’m kind of getting through them (the tablets
prescribed) because I’ve had this many outbreaks, and now I need to come back to you
and chat about it more’. (participant 2)
The reliance of the interactions within this service on text and photographs offers
further temporal affordances that in-person care does not. Service users can keep
CULTURE, HEALTH & SEXUALITY 7
photographic records to show changes in the lesion or keep advice given in text mes-
sages, unlike the verbal exchanges that happen in clinics and are usually only docu-
mented in the medical record kept by the health service. One participant mentioned
that they had kept copies of the photographs they had submitted, and others
reported that saving the text message communication with SH:24 clinicians. They
sometimes referred to these messages during the interview. Such materials operated
as an informal medical record, saved on people’s smartphones.
The tension between anonymous and personalised care
Service users also valued the disconnection in time and space with the clinician who
assessed their genital photographs. Although the clinicians know basic details about
the service user (name, age, ethnicity, clinical history) they have limited knowledge
about their appearance or behaviour except for clues from the photographs and text
message interactions. Similarly, users know little about the clinicians. Photographs and
the names of the clinicians are provided on the SH:24 platform but which of these
individuals completes the assessment of their photograph is not shown. This is more
anonymous encounter than is experienced in a face-to-face sexual health examination,
which may generate feelings of embarrassment, shame or stigma (Cook 2011;
Newman et al. 2020).
Users reported going online to avoid the ‘overwhelming’feeling of walking into a
clinic and navigating reception and the waiting room, the consultation and the exam-
ination. The sense of exposure is significant even when staff are friendly and accom-
modating but participants acknowledged that staff could also be judgemental.
I don’t have to go and see anybody I don’t know face-to-face, so there was kind of
reassurance that I was a little bit happy about. To have to sit there …and explain it all
and show people things, that’s not nice. …I would have done it if I’d had to obviously,
but it would be a big thing. I would be sweating, palms, I know what I’m like, I’dbe
panicking inside (participant 7)
And sometimes like people are sassy in those rooms. Like even I’ve had someone took
my blood and they’re like, ‘Have you have unprotected sex?’and I was like, ‘No’. She’s
like, ‘Sure about that?’She just gets sassy. (participant 6).
By contrast, while taking a photograph of their genitals may have been a difficult
technical exercise, people felt less vulnerable when sending it through to a face-
less clinician.
I think possibly it’s less uncomfortable to just send a photo, because it is more
anonymous –even if it has your name attached to it …. Because I don’t know who sort
of did the diagnosis in this case. (participant 8)
However, for some participants, moving assessment of lesions from an in-person
examination in a clinical setting to the examination of a digitised image created new
concerns since that latter required a process of taking photographs that could itself
compromise the privacy of diagnosis and treatment. In some cases, other people per-
sonally known to service users were implicated in the interactions that were part of
their attempts to achieve an accurate photograph. For example, one user took the
photographs in the toilet at work and the flash went off as someone else entered the
8 P. BARAITSER AND D. LUPTON
area. Another participant reflected on whether it would be appropriate for a partner
to help with taking the image.
Configuring digital privacy
When sexual health information goes online, the potential for sensitive data to be
hacked or inadvertently breached is present (Newman et al. 2020). However, although
the anonymity offered by online sexual health services such as SH:24 is dependent on
the maintenance of strong data security systems, very few participants expressed con-
cern about data security or described checking the digital security of the site. Some
people reported uploading the photographs and then having a momentary sense of
concern, but most trusted the reassurances about security on the SH:24 platform. They
assessed the ability of the service to provide the diagnosis and treatment requested,
the presence of a National Health Service logo, and the involvement of health profes-
sionals working for the service as signs that data security was adequate. As participant
2 put it,
I think it’s a very scary feeling just to put some irritated genitals on the internet and hope
for the best …… I did have trust and confidence in the service because there were
follow-up messages. So there’s those follow-up texts, ‘How is everything working?’
In contrast, users were more concerned that the usability (or lack of usability) of
the SH:24 digital interface combined with their ability to control their technologies
(smartphones) might compromise their digital privacy. Some were concerned about
losing information or images from the digital interface due to inactivity while they
took the photographs. Others were concerned that with several tabs open on their
phones, working on a small screen might result in photographs sent to the wrong
place or that messages from the service might be visible to others as they appeared
on their phones.
I guess you’ve got to do it on your phone because you’re taking a photo. So, maybe the,
you know from like a website point of view, maybe the buttons are quite small. And
obviously I didn’t want to take a photo and like accidentally send that elsewhere. I was
confident in the brand, actually. I thought I, yes, I felt like that would be fine.
(participant 5).
These concerns added to the stress of the self-managed elements of the interac-
tions of users with the affordances of SH:24. They underlined how the automated
responses from the platform that acknowledged receipt of the photographs in a
timely way were very important.
When automated care is not enough
In participants’accounts, there was an expectation of care from digital services includ-
ing care enacted during the design of the service, through automated features and
through personalised, responsive interaction. When the usability of the interface
offered by the service was good, users acknowledged and appreciated this, experienc-
ing it as a sign of care that engendered trust. However, at key moments in their use
of the service, users sought the overt engagement of human clinicians. For Participant
CULTURE, HEALTH & SEXUALITY 9
8, for example, the affordance of direct text messaging with the clinicians answering
their questions was important to their experience:
I asked specific questions. And I got answers back. I think it’s just that sort of one-to-one,
you know, like talking to a doctor, that you can tell that it wasn’t an automated message
…when I was writing back and forth, like it was clearly someone writing.
The obvious engagement of humans in the digital service seemed particularly import-
ant when a diagnosis is made, when users are told that the lesion they were concerned
about was normal and the care episode was closed or when they were unable to
upload photographs that are sufficiently clear for diagnosis and were referred to a clinic.
At these times, users expect an empathetic and supportive response and a rapid transi-
tion to care that was personalised, that explained and contextualised the response from
the service, and which offered practical information on next steps.
The feedback on the photos was, ‘Oh yes, sorry, we’re not going to be able to help you
at this time’. There was no sort of personal touch. Not saying that everyone has to sit on
the phone with someone for hours and hours. But, you know, it was just very –yes,
‘What do I do now?’sort of thing. Yes, so …there was no clarity to why they’d decided
not to help or why they can’t. So maybe if you just got given some reason, or even if it’s
like a tiny reason: ‘the picture wasn’t clear’, or, ‘we’re not too sure …’ Because you can
imagine how a person feels, probably like really embarrassed. And like, yes, already you’re
feeling not great with what’s going on. And then you’ve been told that they can’t help
you and you’ve gone through all of that and there’s just nothing (participant 7).
This account emphasises the affective responses –feeling ‘not great’and ‘really
embarrassed’–that were generated when a relational connection that had been
established with and through a SH:24 clinician appeared to be broken or weak.
Service users placed a significant degree of trust in clinicians by uploading their sensi-
tive information and could feel very vulnerable when awaiting a diagnosis.
…because it is care, it is a care service that you are providing, and if you just have that
little bit of, ‘oh okay, it’s not all doom and gloom, I’m not going to have to sit here with
this herpes’, I think it would make a massive difference. (participant 7)
Discussion
In a new world of digital health services, expectations of care are still being negoti-
ated. In this study, we investigated processes of care through detailed observation to
understand their implications for clinical safety, user experience and service design
within digital health care. As digital services change the practicalities of health service
delivery, new possibilities for health care are both created and closed down. Adopting
a more-than-human approach, our analysis describes how digital services change
familiar strategies for caring as the multisensory elements of in-person diagnosis and
treatment are limited and new opportunities for caring-at-a-distance emerge.
Creating care in this context requires new processes of invention as humans and
nonhumans work together within digital and non-digital spaces. These accounts by
SH:24 service users demonstrate the complex interactions of humans, platforms, digital
devices, other nonhuman agents and place and space. Finding and engaging with the
SH:24 platform involved a set of competencies and invisible labour from service users.
10 P. BARAITSER AND D. LUPTON
The journeys to the online service described by participants show a complex system
of face-to-face and digital care with few connections between them. Once engaged
with the digital service people used unfamiliar modes of communication with clini-
cians, including text messaging and the uploading of highly sensitive personal infor-
mation such as descriptions of sexual activity, symptoms and images of their genitals.
New experiences of care at a distance were most clearly seen in the apparent
contradiction between the value of both anonymous and personal elements of care.
Anonymous care, where there is a disconnect in time and space between the user
uploading the photographs and the clinician assessing them and there is no visual or
haptic contact between them, was valued because it reduced the affectively over-
whelming aspects of in-person clinical examinations and changed the potential expos-
ure to negative (impolite or judgemental) responses from clinicians. The distance that
this generates may not be ‘disengaged’(Puig de la Bellacasa 2017) in this context,
where clinicians pay close attention to the photo-diagnosis process, but it may relieve
the affective stresses of in-person diagnosis. However, at key moments, personalised
care, where clinical advice and support is offered in a way that signals the presence of
humans, and offers engagement with them, is expected and valuable.
The idea of distance within clinical encounters is not new, but its value is often
framed in terms of the boundaries of clinical relationships that ensure that professional
codes of conduct are maintained. The value of distance in standard clinical processes
such as diagnostic examination is used to maintain boundaries within a process that
contravenes the rules of normal social interaction (General Medical Council 2013). It is
only when care delivered by collaborations of humans and nonhumans offers an alter-
native that the value of distance is made visible and a ‘scale of closeness’is offered
where users may choose a level of human engagement that is potentially responsive to
needs. This may be an automated text message at the time of uploading the photo-
graphs or a text conversation with a clinician at the time of the diagnosis.
This finding is consistent with recent work on HIV testing apps that highlight the
strong affective components, both positive (comfort, relaxation, care) and negative
(fear, frustration, worry) associated with their use. In this context, users also valued the
anonymity of the app but were disappointed in the lack of nuanced and responsive
care it could offer (Janssen et al. 2021). Within the setting that we studied, human
clinical support was available but not sufficiently responsive to changes in the level of
human engagement preferred. We found the same expectation of care and disap-
pointment when it was not available. We note that the disappointment was particu-
larly significant concerning transition into and out of a service: for example, making
the decision to upload photographs; managing the information that the lesions that
were causing concern are normal; or managing a clinical referral because a diagnosis
could not be made from the photographs.
We also note that positive relational experiences of care at a distance rely on a
practice of care that separates the time when humans invest care and time when non-
human agents deliver that care. For example, practical tips on how to use a treatment
are written by humans at the time of service development and delivered by machines
when they are needed and stored on phones for future reference. As with the clini-
cians’assessment of the personal photographs, distanced care does not mean that
humans are absent or disengaged from the care process, just that their input is
CULTURE, HEALTH & SEXUALITY 11
separated in time from the moment of delivery. Understanding and valuing the
human input in apparently distanced care is important in describing care within digital
service delivery. Care at a distance relies heavily on self-care and in our case study the
process of taking photographs was difficult and stressful for some (although often less
overwhelming than an in-person examination). Users felt badly let down when their
efforts did not generate the intended result: for example, when the photographs were
of insufficient quality to make a diagnosis. Acknowledgement and support for self-care
within digital health services is an essential part of care within this context. Failure to
do this risks replicating the invisibility of self-care labour commonly found in other
health care settings (Oudshoorn 2008).
Concluding comments
Our analysis asked how sexual health care can be re-thought in an environment where
objects entangle with human bodies to generate affective forces and relational con-
nections that open up or close down possibilities to achieve wellbeing and good
health. Early iterations of telemedicine used video consultations that sought to re-cre-
ate a traditional consultation where clinicians and service users are visible and present
at the same time if not the same space. Subsequent iterations of telemedicine have
drawn from other contexts such as social media, delivering asynchronous, text-based
consultations. As new spaces for clinical interaction are generated, paying attention to
emerging practices and configurations of care becomes important.
Notes
1. The service was awarded a Beazely Designs of the Year Award, a UKUX award, and a public
service award by The Guardian newspaper.
2. Additional material to support our findings is available in the online supplementary material
published with this paper
Acknowledgements
We are grateful to research participants and the thoughtful comments of the reviewers.
Disclosure statement
Paula Baraitser is medical director of the online sexual health service, SH:24.
Funding
This research was partly funded by a King’s Health Partners Research and Development
Challenge Fund Grant.
ORCID
Paula Baraitser http://orcid.org/0000-0002-3354-6494
Deborah Lupton http://orcid.org/0000-0003-2658-4430
12 P. BARAITSER AND D. LUPTON
References
Andrews, G., and C. Duff. 2019.“Matter Beginning to Matter: On Posthumanist Understandings
of the Vital Emergence of Health.”Social Science & Medicine (1982) 226: 123–134. doi:10.1016/
j.socscimed.2019.02.045
BASHH. 2014. British Association for Sexual Health and HIV. Anogenital Herpes, 2014. Accessed
on 30 March, 2020. https://www.bashh.org/guidelines
Bennett, J. 2010.“A Vitalist Stopover on the Way to a New Materialism.”In New Materialisms:
Ontology, Agency and Politics, edited by Diana Coole and Samantha Frost, 47–69. Durham, NC:
Duke University Press.
Church, K., J. Gassner, and M. Elliott. 2020.“Reproductive Health Under COVID-19 –Challenges
of Responding in a Global Crisis.”Sexual and Reproductive Health Matters 28 (1): 1–3.
Cook, C. 2011.“’About as Comfortable as a Stranger Putting Their Finger Up Your Nose’:
Speculation About the (Extra)ordinary in Gynaecological Examinations.”Culture, Health &
Sexuality 13 (7): 767–780.
Courtenay, T., and P. Baraitser. 2021.“Online Contraceptive Discussion Forums: A Qualitative
Study to Explore Information Provision.”BMJ Sexual & Reproductive Health 47 (3):e5.
CQC (Care Quality Commission). 2021. Accessed on XX 2021. March, https://www.cqc.org.uk/
Crath, R., A. Gaubinger, and C. Rangel. 2019.“Studying the ‘Sexuality-Health-Technology Nexus’:
A New Materialist Visual Methodology.”Culture, Health & Sexuality 21 (11): 1290–1308.
Davis, L., and J. Chouinard. 2016.“Theorizing Affordances: From Request to Refuse.”Bulletin of
Science, Technology & Society 36 (4): 241–248.
Douglas, N., and C. Free. 2013.“’
Someone Batting in My Corner’: Experiences of Smoking-
Cessation Support Via Text Message.”The British Journal of General Practice 63 (616):
e768–e776.
General Medical Council. 2013.“Good Medical Practice.”https://www.gmc-uk.org/-/media/docu-
ments/good-medical-practice–-english-20200128_pdf-51527435.pdf?la=en&hash=
DA1263358CCA88F298785FE2BD7610EB4EE9A530
Gibson, D. 2019.“KhoiSan Indigeneity and Entangled Becomings with Kanna, a Teacher Plant.”
Catalyst: Feminism, Theory, Technoscience 5 (2): 1–5.
Grenfell, P., N. Tilouche, J. Shawe, and R. French. 2021.“Fertility and Digital Technology:
Narratives of Using Smartphone App ’Natural Cycles’While Trying to Conceive.”Sociology of
Health & Illness 43 (1): 116–132.
Health England, P. 2020.“Sexually Transmitted Infections and Screening for Chlamydia, 2019.”
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_
data/file/914184/STI_NCSP_report_2019.pdf
Hern
andez, K., J. Rubis, N. Theriault, Z. Todd, A. Mitchell, B. Country, L. Burarrwanga, R.
Ganambarr, M. Ganambarr-Stubbs, and B. Ganambarr. 2020.“The Creatures Collective:
Manifestings.”Environment and Planning E: Nature and Space 4 (3): 838–863.
Ippoliti, N., and K. L’Engle. 2017.“Meet Us on the Phone: Mobile Phone Programs for Adolescent
Sexual and Reproductive Health in Low-to-Middle Income Countries.”Reproductive Health 14
(1). doi:10.1186/s12978-016-0276-z
Janssen, R., N. Engel, N. Pant Pai, A. Esmail, K. Dheda, R. Thomas, and A. Krumeich. 2021.“’You’re
Only There on the Phone’? A Qualitative Exploration of Community, Affect and Agential
Capacity in HIV Self-Testing Using a Smartphone App.”Sociology of Health & Illness 43 (3):
591–606..
Karlsson, A. 2019.“A Room of One’s Own? Using Period Trackers to Escape Menstrual Stigma.”
Nordicom Review 40 (s1): 111–123.
Looker, K. J., C. Johnston, N. J. Welton, C. James, P. Vickerman, K. M. E. Turner, M.-C. Boily, and
S. L. Gottlieb. 2020.“The Global and Regional Burden of Genital Ulcer Disease Due to Herpes
Simplex Virus: A Natural History Modelling Study.”BMJ Global Health 5 (3): e001875.
Lupton, D. 2015.“Quantified Sex: A Critical Analysis of Sexual and Reproductive Self-Tracking
Using Apps.”Culture, Health & Sexuality 17 (4): 440–453.
CULTURE, HEALTH & SEXUALITY 13
Lupton, D. 2019.“Toward a More-Than-Human Analysis of Digital Health: Inspirations from
Feminist New Materialism.”Qualitative Health Research 29 (14): 1998–2006.
Lupton, D., and S. Maslen. 2017.“Telemedicine and the Senses: A Review.”Sociology of Health &
Illness 39 (8): 1557–1571.
Mol, A. 2008.The Logic of Care: Health and the Problem of Patient Choice. London: Routledge.
Mortensen, G. L., and H. K. Larsen. 2010.“The Quality of Life of Patients with Genital Warts: A
Qualitative Study.”BMC Public Health 10 (1): 113.
Nanda, P., and S. Tandon. 2019.“The Times They Are A-Changin”: Using Technology for ASRHR
in the 25 Years Since ICPD.”Sexual and Reproductive Health Matters 27 (1): 1676023–1676051.
Newman, C., J. MacGibbon, A. Smith, T. Broady, D. Lupton, M. Davis, B. Bear, N. Bath, D.
Comensoli, and T. Cook. 2020.Understanding Trust in Digital Health Among Communities
Affected by BBVs and STIs in Australia. Sydney: UNSW Sydney. http://unsworks.unsw.edu.au/
fapi/datastream/unsworks:72141/bin9ea3e01e-327a-44d7-835a-8e560be6987f?view=true&xy=01
Nicolini, D. 2011.“Practice as the Site of Knowing: Insights from the Field of Telemedicine.”
Organization Science 22 (3): 602–620.
Oudshoorn, N. 2008.“Diagnosis at a Distance: The Invisible Work of Patients and Healthcare
Professionals in Cardiac Telemonitoring Technology.”Sociology of Health and Illness 30 (2):
272–288.
Piras, E., and F. Miele. 2019.“On Digital Intimacy: Redefining Provider–Patient Relationships in
Remote Monitoring.”Sociology of Health & Illness 41 (S1): 116–131.
Pols, 2012.Care at a Distance: On the Closeness of Technology. Amsterdam: Amsterdam
University Press.
Puig de la Bellacasa, M. 2017.Matters of Care: Speculative Ethics in More Than Human Worlds.
Minneapolis: University of Minnesota Press.
"SH:24". Accessed on 28 February, 2021. https://sh24.org.uk/
Sonnenberg, P., C. Tanton, D. Mesher, D. King, S. Beddows, N. Field, C. Mercer, K. Soldan, and A.
Johnson. 2019.“Epidemiology of Genital Warts in the British Population: Implications for HPV
Vaccination Programmes.”Sexually Transmitted Infections 95 (5): 386–390.
The Design Council. 2015.“What is the Framework for Innovation?”https://www.designcouncil.
org.uk/news-opinion/what-framework-innovation-design-councils-evolved-double-diamond
Trimble, H. 2016. "How the Sexual Health: 24 Service Used GOV.UK Patterns." GOV.UK.
Wilkinson, J., C. Roberts, and M. Mort. 2015.“Ovulation Monitoring and Reproductive Heterosex:
Living the Conceptive Imperative?”Culture, Health & Sexuality 17 (4): 454–469.
Wilson, E., C. Free, T. P. Morris, J. Syred, I. Ahamed, A. S. Menon-Johansson, M. J. Palmer, S.
Barnard, E. Rezel, and P. Baraitser. 2017.“E-STI Testing and Results Service: A Single Blind
Randomised Controlled Trial.”PLoS Medicine 14 (12): e1002479.
14 P. BARAITSER AND D. LUPTON
