Breaking down barriers to conversations about sexual and reproductive health

Howard et al1 have produced a timely and comprehensive overview of the field of women's reproductive mental health, which offers a stark reminder of the significant work that will need to be done to address the relevant health disparities. Here I focus on the barriers to integrating women's sexual and reproductive health issues into mental health care and propose some possible solutions. Whilst attitudes towards women's sexual and reproductive health have significantly shifted in mental health care, some of the core beliefs about women's rights to autonomy over their own bodies and reproductive choices may still prevail. I believe that the current mental health system, which is risk-averse and paternalistic, must change significantly in this respect. Howard et al note that mental health practitioners tend to avoid talking about sexual and reproductive health issues due to lack of knowledge and uncertainty. I would argue that, whilst lack of knowledge is a key barrier, there are other significant and complex reasons why these topics are avoided. Identifying and addressing these issues will be critical if practice is to change. When I undertook focus groups with mental health clinicians about the sexual health needs of people with mental illness2, these professionals began to discuss the issue through a lens of risk and safeguarding. They were aware that some people were engaging in risky or abusive sexual relationships, but were uncertain about what their role was in addressing this. There was real concern about raising the topic of sexual and reproductive health, as they feared all sorts of negative consequences. They were worried that people would be offended, or that this could damage the therapeutic relationship up to triggering a trauma reaction (in those with a history of sexual abuse). They were aware that many of the people on their caseloads had sexual violence histories, but they felt that this group should not be exposed to these topics. Whilst well-intended, this paternalistic attitude neglects the needs of marginalized people who could be at continued risk of harm. In addition, avoidance of the topic removes the opportunity to talk about what has happened, and get some support. In fact, it may be another form of silencing people which is inadvertently replicating the patterns of abusers. There is evidence3 that, despite the high levels of sexual violence experienced by women with mental illness, routine enquiry is not taking place. Even if a disclosure is made, the woman is not always referred to appropriate services, and the disclosure is not always believed. Indeed, in the focus groups, mental health practitioners were unsure of available local services and what to do about sexual and intimate partner violence. In addition to paternalism, another factor can be the gender difference between the staff and the person with mental ill health. In the focus groups, male staff participants expressed concern about asking female patients about sexual and reproductive health: “To be questioning somebody about an intimate part of their life… outside of the framework of what I'm supposed to do during my assessment makes you feel uncomfortable… you know, you're untested waters”2. In addition, participants of both genders expressed the idea that conversations may be more comfortable if the staff member and the person with mental illness were of the same gender: “Maybe it is gender specific then, because on the ward where we work with women, I've known males sort of like brush over the question… like the females on the ward feel more comfortable talking to the female members of staff about that”2. In a subsequent survey of mental health nurses regarding sexual and reproductive health4, it was also noted that male participants were more comfortable talking to male than female patients. The consequences of avoiding sexual and reproductive health issues for women living with mental illness are stark. They are less likely to take up breast and cervical screening, and this may explain their higher cancer mortality5. Whilst fertility is lower in women with severe mental illness, the rates of unintended pregnancy and abortion is higher, and there is evidence that these people are at increased risk of human immunodeficiency virus (HIV) and other sexually transmitted infections. In addition, women with mental illness are more likely to have experienced sexual abuse and violence6. In order to address the sexual and reproductive health inequalities for women with mental illness, it is important to overcome the structural and interpersonal barriers that have been identified in mental health care settings. This will require top-down leadership to ensure that women's reproductive health is integrated into mental health holistic assessments. In our focus groups, it was interesting that, after spending some time reflecting on the topic (and discussing how challenging they found it), the participants (without prompting) started to discuss solutions. There was a consensus that sexual and reproductive health should be a part of holistic mental health care: “Actually, it is something that we need to address, because it does affect a lot of other sort of things about the person's care”3. In order to support integrating this topic into mental health, organizational commitment was seen as important and a way of legitimizing its inclusion. Some participants felt that a standardized form would help them in starting the conversation. Having a “sexual and reproductive health” champion would also help keep this on the agenda. While it would be important for people with mental illness to be able to access specialist sexual and reproductive health services, this should not be simply a case of signposting the person to these services. Participants recognized that people with mental illness might benefit from having an advocate to assist them to connect to the other services in a more supportive and proactive way. Participants also discussed their own knowledge and training needs. They noted that there was no inclusion of sexual and reproductive health in mental health nurse training. The training just involved knowledge of sexually transmitted infections and how to support people regarding high risk sexual behaviors. Increased conversations about sexual health in care notes was documented after offering mental health staff some specific training7. Of note, very little is known about the perspective of people with lived experience on this topic, including preferences around when and whom to have the discussions with. Whilst mental health practitioners have concerns about how conversations about sexual and reproductive health may negatively impact people, there is little evidence to support this. A randomized controlled study8 of a sexual health promotion intervention for people with severe mental illness (which included collecting data on sexual risk behavior, and use of contraceptive and sexual health services) demonstrated that it was acceptable and feasible to engage people from secondary mental health care, and no adverse events were reported. In a meta-synthesis9 of qualitative studies related to sexuality in people with severe mental illness, the participants identified a range of areas of need, including wishes to have children and sexual side effects of psychiatric medication, and expressed the desire to talk to someone about these issues. So, in conclusion, mental health practitioners are aware that women with mental illness have sexual and reproductive health needs, but are unclear about what their role should be in addressing these issues. This is compounded by policy and practice drivers at an organizational level as well as a genuine concern that raising these topics could have a detrimental impact on people with mental health problems. Any initiatives that aim to improve women's sexual and reproductive health in mental health services will need to address these challenges around knowledge, attitudes and confidence amongst mental health practitioners.