What is needed to improve young people's access to sexual health care through primary care?

Abstract

Successful sexual health care at both individual and population level relies on access to health practitioners who can provide non-judgemental, sensitive and clinically appropriate care. It is well established that young people (here defined as 15–29-year-olds) encounter many barriers in accessing health care through primary care, where most sexual health care is delivered to young Australians. The evolving nature of general practice towards management of multimorbidity and chronic care for older age groups provides both a concern and an opportunity for the future sexual health care of young people and will require continued development of innovative models.

Most Australians become sexually active at the age of 15 years.¹ Although many young people have positive experiences of exploring their sexuality during adolescence, the risk taking and experimentation common to this life stage (eg, condomless sex, multiple sexual partners) can put individuals at risk of adverse outcomes, including sexually transmitted infections (STIs) and unintended pregnancy.

Young people account for most STI notifications in Australia, and are a priority population for STI control.² STI incidence has increased in recent years, and, in 2022, 69% of the 93 777 chlamydia notifications in Australia were among 15–29-year-olds.³ Untreated infections can have severe and potentially irreversible health impacts, particularly for women of reproductive age (eg, infertility²), and opportunistic testing is key to detecting asymptomatic infections.

It is recommended that general practitioners discuss intentions for pregnancy with all female patients of reproductive age, and provide pre-conception and contraceptive care accordingly.⁴ Although national abortion data are unavailable in Australia, unintended pregnancy is common and often experienced by women when they are aged under 30 years.⁵

Along with STI testing, contraceptive care, and termination of pregnancy, primary care practitioners also manage other sexual health issues in young patients including period pain, endometriosis and other pelvic pain, infertility and miscarriage, and sexual assault and violence. Young people's sexual health interests, however, extend well beyond such reproductive issues. Our recent research, involving a survey of 1887 young people, identified that many would like to discuss certain concerns with their general practitioner that may not be considered as pressing issues for young people.⁶ For example, we found 16–29-year-olds were most likely to say they would like to discuss sexual dysfunction and difficulties with their general practitioner. In addition, a high proportion of young women wanted to discuss cervical screening with their general practitioner, even when not yet eligible.⁶ These findings go against assumptions about young people's priorities and suggest some interest in preventive health.

Ensuring that sexual health care is affordable, accessible and acceptable is key to improving population health. Many young people access STI testing and other sexual and reproductive health care through general practice,² but data on bulk-billing and low cost services for this age group have not been published. Other services including specialist sexual health and community health services may also provide this care, often to hard-to-reach or priority populations. However, to leave these services with the capacity to manage priority patients and/or complex cases, general practitioners must also be supported to provide sexual health services to the general population.⁷

General practitioners play a key role in preventive health and health promotion, being in a prime position to enquire opportunistically about patient health concerns. The Royal Australian College of General Practitioners’ general practice curriculum notes that general practitioners should proactively raise sexual health and be prepared to discuss sex with all patients, regardless of their identity and background.⁸ Rapport and relationship building with young patients is key to such discussion, and a wealth of literature demonstrates the benefits of continuity of care on the patient experience and outcomes.⁹

Substantial recent literature has identified barriers to young people's access to health care in Australia. Structural barriers such as high costs, long waiting times, and lack of transportation can prevent young people from seeking care.^{10, 11} Navigating the health care system can also be difficult; many are unaware of where to access sexual health care, or perceive it to be difficult to do so.¹ These barriers may be felt more acutely by certain populations; for example, young people living in rural and remote areas, those from lower socio-economic backgrounds, those who are Aboriginal and Torres Strait Islander, and those from culturally and linguistically diverse backgrounds.

Barriers to accessing care are further exacerbated by the ongoing societal stigmatisation of sex and sexual health. Young people may feel too embarrassed to raise their sexual health with a health care provider, worry about being judged or discriminated against within health care settings, and may be concerned about their privacy and confidentiality.¹¹ Again, some population groups may be disproportionately affected by these barriers. Rural and remote youth can struggle to access care discreetly or anonymously.¹² Young culturally and linguistically diverse people from some cultural backgrounds may experience a higher level of internalised or societal stigmatisation.¹³ Lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) young people are also more likely to experience stigma and discrimination outside and within health care settings, which can have an impact on their ability and willingness to access care or disclose their sexuality.¹⁴

In addition to barriers encountered by young people, general practitioners are currently experiencing challenges that reduce their ability to provide time consuming, comprehensive care. The primary care system is in a state of crisis, arising from years of underfunding, ongoing pressures and fallout from the coronavirus disease 2019 (COVID-19) pandemic, alongside an ageing population with rising rates of chronic disease and mental health issues.¹⁵ Unfortunately, the situation is set to worsen, particularly outside major cities, as the system becomes unsustainable for many general practitioners and the demand for services increases.¹⁶ Within this context, primary care providers often do not have the time to opportunistically discuss sexual health or provide preventive sexual health care.¹⁷ Sensitive topics can take substantial time to address or investigate, especially when young people are reluctant to initiate discussion or respond readily to questions in the clinical setting.

Improving sexual health care in the primary care setting requires attention to policy, overcoming consumer access issues, and recognition of the barriers faced by sexual health practitioners. The Strengthening Medicare Taskforce has provided several recommendations to bolster primary care more generally.¹⁸ Notably, the recommendations to increase funding to support Australians who have a low income to access affordable care and to increase the availability of after-hours primary care services may help overcome some structural barriers that young people encounter. In addition, young people are more likely to enter youth-friendly primary care spaces and respond to known enablers of youth-friendly consultations — these should also be considered.¹⁹

Digital health care is growing rapidly, and young people use it to navigate and experience all levels of the health system in a way their parents may not.²⁰ Many use online menstrual trackers, as well as social media platforms to seek information on managing specific conditions or lived experience. They search reputable websites for health information to support their interactions with service providers, even though their knowledge is sometimes dismissed by practitioners who have little digital experience.²¹

Health promotion campaigns should consider what is needed by young people to access care. Various reputable organisations have provided clear and reliable advice and online information resources, both for the general population and for priority groups. This includes, for example, websites with information about what to expect from an STI test,²² young people's rights when accessing care,²³ and the Australian health care system and sexual health for international students.²⁴ Although it is encouraging that these resources are freely available, these valuable messages may not be reaching all people who need them. Characteristics that make sexual health promotion programs for young people successful (eg, repeated interventions, parental involvement, inclusion of skills building)²⁵ should be considered when designing and promoting resources. Furthermore, readily available information should be provided about cost, including bulk-billing and Medicare cards.

In recent years, various programs have been implemented to provide priority and traditionally hard-to-reach populations throughout Australia with sexual health care. Ongoing support for these important initiatives, such as point-of-care STI testing for remote communities²⁶ and doctors in schools’ programs,²⁷ is vital to ensure equitable access to care for marginalised young people. Both policy and financial investment into nurse-led care will assist contraception and medical abortion provision, particularly in rural settings,⁵ and may be suitable for a range of sexual health care. Online sexual health clinics can be safe and feasible,²⁸ and expansion of and continued investment into successful digital and in-person programs and services will ultimately allow outreach to young people who may otherwise be unable to access care.

Access to sexual health care is vital to improving the health and wellbeing of young people, but many young Australians continue to face structural and societal barriers to accessing care. Strengthening the primary care system will assist health care practitioners with the time and resources to provide good sexual health care. Continued investment into innovative strategies and programs to serve hard-to-reach young people is also needed, as well as consideration of how to better promote key information about services to young people throughout Australia.

Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians.

No relevant disclosures.

Commissioned; externally peer reviewed.