“My issues would be somebody’s dinner time conversation”: The social barriers women face to access sexual and reproductive health services in rural and regional Australia

Justine attended the United Nations' Commission of the Status of Women 62 (CSW62) in 2018 and is currently studying a Bachelor of Arts (Media and Communications) at the University of Sydney. She is also the current editor of Australia’s most famous student newspaper, Honi Soit, and have led groundbreaking investigations into campus sexual assault that have contributed to institutional change.

 

Recommendations

1.    Investigate and encourage opportunities for partnership and collaboration between schools and existing sexual health services to improve accessibility for school-aged women in rural and regional Australia;

2.    Recalculate the distribution of state-level school funding based on the development of programs between schools and sexual health services to deliver sexual health services and resources to school-aged girls in rural and regional Australia, in order to incentivise the adoption of such initiatives.

 

Introduction

This paper argues that Australia’s existing policy framework for addressing adolescent access to sexual health services attempts to mitigate the geographical and practical barriers for rural and regional young women, but fails to address the social and cultural barriers they face.

The first part of this paper will canvass the social barriers for women to access sexual health services in regional Australia and examine the effectiveness of existing policies to address these barriers. The second part of this paper recommends the adoption of government policies that encourage the provision of sexual health services within public high schools. 

 

Background

The World Health Organisation defines sexual and reproductive health as “a state of physical, emotional, mental and social well-being; not merely the absence of disease dysfunction or infirmity." Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (2006, pg. 4). To have reproductive health means to have a “satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so” (International Conference of Population and Development, 1994, pg. 59).

Access to sexual health care is considered paramount to women’s empowerment.  As Lukshimi Prui said at the 2013 EuroNGO conference, “there is an inextricable link between sexual and reproductive health and rights and gender equality and women’s empowerment”. Furthermore, the Beijing Pact states women have their right to “decide freely and responsibly on matters related to their sexuality… free of coercion, discrimination and violence” (United Nations Women, 1995). In communities where family planning is supported, women’s access to education, stable employment, healthy relationships, and economic security are enhanced (Astbury, J, 2008, pg. 44-59).  

In Australia, while teenage pregnancy has declined overall, studies show it is significantly higher in rural and regional communities (Larson, 2013). Difficulties accessing a range of contraceptive options has been argued to contribute to the relatively high number of teenage births in rural communities (Australian Institute of Public Health and Welfare, 2011; Pursche, 2007; The Royal Australian College of Physicians, 2015). Women living in these areas are also more likely to contract a sexually transmittable disease (Miller, 2018). The necessity of this research paper is premised on the understanding that disadvantageous sexual health outcomes will continue to disproportionately affect women living in regional communities unless new policies are developed that recognise this unique matrix of avoidable and inequitable social and geographical challenges. 

 

Part One: Identifying Barriers

Several qualitative and quantitative studies have examined young people’s perceptions of sexual health services in rural and regional towns globally and identified the reasons why adolescents avoid accessing these services. The purpose of this section is to examine the recognised social barriers to sexual health care and corroborate these findings with anecdotal responses I collected from women who have tried to access such services in regional Australia. 

 

Australia’s current policy focus

Practical and educational barriers to accessing these services in regional towns are already widely-acknowledged and responded to by academics, policy-makers and the broader Australian community. The Royal Australasian College for Physicians (2015, pg. 14) recognizes that distance, experience, service scarcity and a smaller workforce all impact young people’s access to health services in rural and remote areas. 

In Australia, the general practice is the preferred site for young people to access primary health care, however, adolescents are under-represented in general practice attendances and are reluctant to seek required sexual health care during such consultations (Matich et. al, 2015). It’s common knowledge that there is a sizeable gap in health care based on where you live in the country. In 2011, the per capita ratio of GPs to the population in major cities was double that of remote areas, and “considerably higher than the ratio of GPS in regional areas” (Australian Bureau of Statistics, 2013). The Australian Bureau of Statistics (2013) study also found the proportion of specialists working in regional areas was around half that in major cities, and very low in remote areas. At a basic level, this disparity affects the ability of young women to practically seek medical help on sexual health matters. A subsequent ABS (2017) patient experience survey found 10 per cent of patients living in outer regional and remote areas had to travel more than one hour to access a general practitioner, compared with less than 2 per cent of people living in major cities. 

In addition, while studies have found a majority of young women prefer to see a female doctor (Stewart and Rosenthal, 1997, pg. 129), research indicates there are a smaller number of female doctors than male doctors practising within rural and remote areas. A report by the Australian College of Rural and Remote Medicine (2003, pg. 6) found only 19 per cent of the Australian rural general practice workforce was female. One survey of women in the Grampians region noted that community care issues including “less chance of seeing a GP of choice” and less chance of seeing a female GP can prevent women from accessing general gynecological care as women “may not want to see a male GP when “dealing with emotional issues and don’t feel like [male GPs] want to go to pink bits” (Kruss, 2012, pg. 94). 

Even when a general practitioner is available, the cost of seeing them can be prohibitive as there is no guarantee these services will be free or bulk billed. Women may also incur the cost of things like emergency contraceptives, which aren’t listed on the Pharmaceutical Benefits Scheme (Cox, 2016). 

A study of young people aged 15-24 from regional and rural Queensland showed that 36.2 per cent preferred to visit a specialist SRH service, due to their specialized knowledge, comfort and a greater sense of confidentiality (Matich et. al, 2015). However, seeing a SRH specialist, such as a gynecologist, can prove even more difficult in regional Australia. There are only thirty-one NSW Government Sexual Health Clinics to cater for the states’ regional and rural communities. For a woman living in Coonabarabran, it’s a two-and-a-half-hour drive to see a GP with a medical interest in family planning and gynecology (NSW Government, 2017); Google Maps can’t calculate a route via public transport, probably because there isn’t one. 

 

Invisible barriers: social hurdles to accessing sexual health care

This essay highlights two social barriers inhibiting rural and regional young women from addressing sexual health matters: concern over a lack of confidentiality, and fear of judgement and sexual shaming.  

Before I can examine the social barriers in earnest, I must canvass the research methodology behind this section. To validate the arguments made herein, I corroborated the qualitative and quantitative findings of secondary source studies with anecdotes from a dozen women surveyed for the purposes of this paper. The qualitative survey received a dozen responses from women living in rural and regional towns including Pinnaroo, Kingscote, Kyneton, Mildura, Geraldton, Armidale, and Coonabarabran. It asked them to describe their experience in accessing sexual health services. The survey was conducted anonymously via a Google form that was distributed via social media. It is important to note that while the responses are illuminative, their representativeness is limited by the online social circles in which they were shared.  

The fear of gossip and perceived lack of confidentiality in regional towns causes many young women to refrain from sharing matters concerning sexual health with their local professional health care provider, such as their GP (Bender and Fulbright, 2013, pg. 165). 

Firstly, studies reveal both young women and young men from such communities are almost unanimous in believing that “sexual health service providers, including chemists, could not be relied upon to maintain their confidentiality” (Warr & Hiller, 1997, pg. 135). Survey and focus group discussions conducted with high school students living in small rural Australian communities found the trust of medical professionals to keep thins confidential is marred by the fact that, due to the size of the town, “many services were staffed by friends, schoolmates, and the friends of brothers, sisters or parents who were suspected to report such visits to their parents and it was the experience of young people that sport was made out of their embarrassment in purchasing items such as condoms” (Warr & Hiller, 1997, pg. 135). As one woman responded to my survey she described her experience in accessing sexual health services in Kingscote: 

“[It was] awkward and a bit embarrassing. Often you’re being treated by people (Doctors, Nurses, Pharmacists) who know you and your family, so having to speak with them about intimate issue can be difficult. I’m often worried that my issues would be somebody’s dinner time conversation so privacy and discretion are huge things for me when selecting a practitioner (although I’m not always spoilt for choice).”

 Another respondent from Armidale echoed similar concerns:

“In a small town you know the doctor, the receptionist, the pharmacist, so accessing these services feels public and not anonymous. It feels uncomfortable to get some health checks by people you know. In small communities, people know your personal/ sexual relations, and despite full confidence in the doctor's confidentiality, it just doesn’t feel right.” 

 Several reports have found that young women are deterred from attending the doctor and sexual health specialists, or purchasing contraceptives from the pharmacy, in case they run into people they know socially (Warr & Hiller, 1997; Johnston et al, 2015; Matich et al, 2015; Bender and Fulbright, 2013). As survey respondents from Kyneton and Armidale respectively wrote: 

“I once had to ask a pharmacist for the morning-after pill and I went to the chemist on a number of separate occasions trying to catch the store at a time where nobody I knew was in there. Fear of judgement and fear of people finding out are definitely on my mind.”

 “I have not had a Pap Smear in a country town as I know the doctors (or my family do) so it seems too personal or intrusive… I time buying some prescriptions when I know my peers aren’t working at the pharmacy.”

As such, young women report feeling as though there are less options available for accessing SRH services in town altogether (Johnston et al, 2015, pg. 260), with service providers from Melbourne’s Grampians regions noting that “rural women have little choice but to see someone they might know socially, unless they travel some distance to access a service” (Kruss and Gridley, 2014, pg. 303). 

This was the case for several survey respondents. For example, a respondent from Mildura admitted to travelling hours to the women’s hospital in Melbourne to see a gynecologist once every three months at her own cost rather than have “anyone in town finding out [because] there’s a perception that the only reason you’d go to a gyno is if you’re pregnant”. Another woman from Nuriootpa said:

If I had not been able to travel to Adelaide, I would not have been able to access sexual health services. In addition to this, as my family is treated by [the town’s doctor] and it is a small town, my details wouldn’t have remained private. I have had a family member go to this doctor to access sexual health services and be told that the doctor was not comfortable examining them so refused to do it.”

As one respondent from Lameroo explained, the fear of people finding out and associated judgement means “it’s just easier on me and my emotions to go elsewhere. Especially [when I need] a pharmacy. I wish this wasn’t the case but just is”.  

The issue of lack of confidentiality and fear of gossip are inextricably linked. Certainly, sexuality is a private matter, the details of which should only be shared at the individual’s wish (Warr & Hiller, 1997). However, a reason why young women in regional communities worry about their privacy being breached when it comes to accessing sexual and reproductive health care is the belief they will be judged by health professionals and members of the community. 

Researchers have observed the close-knit and suspicious nature of rural towns. In small communities, where everybody is known, the observed behaviour of individuals can be quickly passed around as common knowledge (Warr and Hiller, 1997, pg. 139). In addition, studies observe conservative attitudes towards family planning and sexual relations are more prevalent in regional Australian towns (Kruss & Gridley, 2014, pg. 304); women fear judgement from medical practitioners and pharmacists due to cultural shaming and the contemporary misapplication of these beliefs.  

There is a significant difference in the way that adolescent men and women feel their sexuality is perceived in regional or rural communities. While both boys and girls have reported feeling their activities are the source of “a great deal of gossip… girls were consistently more likely to feel their activities were inhibited for fear of community disapproval” (Warr & Hiller, 1997, pg. 135). Interviews with men and women from regional communities found that rigid, and often contradictory, social expectations governed women’s sexuality; while many young men expected girls to be sexually available in a relationship, those who were perceived as too sexually active were labelled sluts (Warr & Hiller, 1997, pg. 139). 

Concerns about privacy and judgement within a small community compound the practical problems of geographical isolation, financial burden and limited choice of service providers experienced by young women living in rural and regional Australia. Johnstone et. al found that, for young people attending school, the ability to access a service confidentially is also hindered by the “availability, acceptability and accessibility of transport to the service, and was amplified by the standard operating hours of a health service” (2015, pg. 260). 

The consequences of these intersecting logistical and social barriers are significant. If young women fear “being labelled by their peers as promiscuous or diseased”, or if condoms must be purchased in a manner that “invites unpleasantness or discomfort”, they will not be less likely to engage in sex but maybe, rather, more inclined to take risks (Warr and Hiller, 1997, pg. 139). This is particularly unhealthy because young vulnerable women in regional towns are often, oxymoronically, expected to carry sole responsibility for organizing contraception (Warr and Hiller, 1997, pg. 139). 

 

 Part Two: Policy Recommendations

This paper recommends policies that facilitate the establishment of school-based sexual health services for young people (SBSYP) to mitigate the social barriers for young women accessing this type of health care. 

SBHYPs can take the form of school-based health centres or health centres that partner with schools to offer these services to students off-site (Alford, 2012). Such clinics, in practice, have offered sexual health care services or in some cases adopted a multidisciplinary approach providing primary sexual and reproductive health care, STI/HIV testing, substance abuse treatment, mental health care, and counselling (Alford, 2012). They were first established in the US in the 1960s, and have gone on to become a popular model of care for adolescents in the US and UK (Ammerman, 2010; Ingram & Salmon, 2010). 

SBHYPs are not foreign to Australia. Stanzel’s retrospective study of a youth health clinic established at a semi-rural school found that the clinic conducted more than a hundred consultations most years of operation. Further, while it is unknown whether there is a link with the clinic’s existence and the absence of positive pregnancy tests at the clinic since 2006, broader research indicates that accessible contraception is a contributor to the decline in unintended pregnancies (Sidebottem et. al., 2003). 

More recently, in 2014 Luke Munmorah High School partnered with the Central Coast Local Health District (CCLHD) to establish the first Youth Health Clinic based on a NSW Department of Education school site. Operating every Wednesday, a local area health nurse and private practice doctor provide bulk-billed consultations with students over 14 years (Lake Munmorah High School, n.d.). The clinic is not limited to providing sexual health care, but treatment for a range of medical conditions including general health concerns, mental health, relationship problems, and drug and alcohol issues (Lake Munmorah High School, n.d.). 

The appeal of SSHYPs are twofold: they provide a greater perception of confidentiality and accessibility for adolescent women when seeking these services.

Confidentiality was the main reason motivating students to attend sexual health clinics at schools across the United Kingdom. In 2006 and 2007, the Brook Advisory Centers voluntary established free and confidential sexual health advice and care drop-in services at 16 schools in South West. During weekly lunchtime drop-in sessions, the clinic – run by a team of six part-time sexual health nurses and two youth workers, along with two part-time managers – provided “support to young people about puberty, relationships, and sexual health” (Ingram & Salmon, 2010, pg. 228). Most schools also provided a full contraceptive service, including prescriptions for oral and emergency contraception, as well as condoms, and referrals for IUD (Intra Uterine Device) insertion.  

 

A study of the clinics located in a large city in South West England surveyed 33 percent of young people who attended the clinic (Ingram & Salmon, 2010, pg. 231). Two-thirds of surveyed students rated the clinic highly, with 75 percent saying it was private (Ingram & Salmon, 2010, pg. 231). However, of the qualitative discussions with 44 of the patients found, several said: “if they did not have access to the school based drop-in, they would not attend an alternative provision” (Ingram & Salmon, 2010, pg. 232). In addition, “several young people thought it would be less embarrassing to use the school-based service than an outside provider because they would feel more comfortable with nurses at the school and that their parents wouldn’t find out (or be worried their GP might know their parents” (Ingram & Salmon, 2010, pg. 233). 

Some students were still concerned about the level of privacy of attending a school clinic, though studies have found evidence to suggest that “broad-based, holistic service models, not restricted to sexual health, offer the strongest basis for protecting young people’s privacy and confidentiality, countering perceived stigmatization, offering the most comprehensive range of products and services, and maximizing service uptake”. This allows for students to “come in for care related to a sensitive issue without worrying that others will know why they are in the health centre” (Owen et al, 2010). 

Statistics speak to the benefits of SSHYPs: the research of Sidebottem et al. (2003) and Rickkets and Geur (2003) shows that, while pregnancy rates had fallen in general, the decrease was notably higher in schools that offered offer SBSYPs. 

Aside from the convenience of attending a clinic on school grounds, partnering with local health care services can allow adolescent women, especially those who are poor or uninsured, to access pharmaceuticals and discounted specialist care.  For example, at the Luke Munmorah High School clinic, the cost of prescription medications is charged to the CCLHD in partnership with local pharmacies, and a variety of allied health service - including psychologists, social workers, and Aboriginal Health Workers - are provided by Youth Health CCLHD for free (Lake Munmorah High School, n.d.). 

Overall, these case-studies suggest broad-based SBSYPs staffed by multi-professional teams could provide the means to overcoming some of the main social barriers, and incidentally practical barriers, deterring young women from accessing sexual health care in rural and regional Australia. School-based clinics are among the best-evaluated models internationally, and we could argue that there is sufficient evidence already for these models to be piloted and evaluated in Australia (Kang et. al., 2006). 

Our nation’s current policy framework – and the UK’s for that matter – is absent of any template for establishing, sustainable funding, or approach to evaluating such clinics within the Australian public school system. The recommendations proposed here attempt to instigate and incentivize the introduction of such programs. 

 

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