Long Read: The Future of Sexual Health in Wales

Kaja Brown interviews Dr Kate Nambiar and Rhys Goode on the sexual health services that Wales’ offers and how these could be more inclusive.

Kaja Brown interviews Dr Kate Nambiar and Rhys Goode on the sexual health services that Wales’ offers and how these could be more inclusive.

Kaja Brown: Could you both tell me about your backgrounds and the work that you do?

Dr Kate Nambiar: I have been a doctor in the NHS since 1999 and I am currently the medical director for the Terrence Higgins Trust (THT).

My background is in sexual and reproductive work. As part of that, I set up a clinic called Clinic T which is a transgender, nonbinary, and gender diverse sexual health service. Last year, I moved to Wales to work in the Welsh Gender Service. I am a trans person myself and I am proud to represent my own community in the work that I do and in the THT too.

Rhys Goode:  My background is largely in politics and public relations. I’ve been involved with activism for a long time and I have also done campaign work. I was part of the group that helped to get equal marriage passed in 2011. After spending a long time in London I then moved back to Wales and as a result have taken on the challenge of leading the THT in Wales.  

Why have you both decided to live in Wales now and what is it like working in Sexual Health here? 

KN: Even though I grew up in London I have always had an affinity with Wales. A job came up at the Welsh Gender Service, run by a colleague and a good friend of mine, and I took it. I have to say, having moved to Cardiff, I wonder why I didn’t do it much earlier. This is a brilliant place to live. There’s a great queer community with lots happening. Plus, with the direction of work we are doing, it is an exciting time to be a part of it. 

Wales has the highest rate of late diagnosis of HIV in the UK, which has far wider implications.

Some things I took for granted working in England don’t really exist here or are in a very embryonic stage. A lot of public health monitoring, e.g. databases for new HIV diagnosis rates going down, don’t really exist here. We don’t have that data in Wales, especially as that reporting is not as robust or comprehensive. So that was a bit of a shock to the system. But when I joined the HIV action plan team here I realised that even though we have a long way to go, we do have a plan and a dedicated and passionate team, so it is an exciting time to be a part of it. 

RG: I never thought that I would move back to Wales honestly. But having moved back it is remarkable reflecting on how Welsh culture felt when I left at eighteen, versus now. It is a completely different world and such a vibrant place. There are so many pockets of culture that have appeared, so many amazing diverse queer spaces across Wales.

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From a sexual health POV, as Kate said, everyone would accept that Wales isn’t where it should be in terms of sexual health. There is a lot of difference in what you can access in central Cardiff versus more rural areas. Even where I am from in Bridgend it is a bit of a black hole since services have been traded back and forth between Cardiff and Swansea and as a result the health boards are disjointed. When I came back after living for fifteen years in London, I re-joined my childhood GP. I had an appointment and I said while I’m here, I am running out of PrEP, so can I get a prescription? And the GP looked at me and said ‘What are you preparing for?’ And that was the moment the bubble burst. 

But as Kate says, it is a really exciting time to be involved in what we are all doing together and trying to get to the zero HIV cases by 2030 target while also reflecting that everyone in Wales needs access to PrEP and decent sexual health services, as right now it is a postcode lottery. 

What services do Sexual Health Clinics offer? 

KN: They offer a broad range of services, but generally they focus on sexual health testing and the management and care of people with genital symptoms – which may or may not be related to sexual conditions. There is a strand that goes with that; contraception, pregnancy testing, referral to abortion services, and a huge amount of work on promotion of prevention and education around sexual health. There is also the caring of people who live with HIV. 

The burden of sexual ill health is very significantly carried by people from minority backgrounds

Why are these services important? 

RG: There is a stat on the Frisky Wales website, where you can order sexual health tests from, that approximately 1 in 10 young people in Wales have Chlamydia without knowing. In the grand scheme of things Chlamydia doesn’t seem like the end of the world but it demonstrates the importance of regular testing. And Chlamydia does have wider impacts if untreated, as does Gonorrhoea. And this is before getting into the world of hepatitis or HIV. 

It’s not so much the service itself but the public knowledge that they exist, and the importance of taking care of your sexual health, that is key. Wales has the highest rate of late diagnosis of HIV in the UK, which has far wider implications. Having a visible presence for sexual health clinics is, in some cases, more important than brick and mortar, and the understanding of how and where you can access these services. 

KN: If you look at the stats, the burden of sexual ill health is very significantly carried by people from minority backgrounds; people of colour, black, gay and bisexual men, and a huge amount of undiagnosed infections amongst trans/non-binary people who may not access care as the services are not set up well for those populations. The visibility of those services and broadcasting what is out there is so important. We have a lot more to do to reach those groups. We can’t just expect people to walk through the door. But the fact is that if you haven’t got a service, that’s the first step, and then you build on that and target those populations. 

RG: I think as well as being visible it has to be accessible to everyone. It has to be clear in every promotion of sexual health that it is for people with a diverse range of backgrounds. We currently face difficulties in terms of trans health and their fear of engaging with these services and that is something we have to look at. When faced with quite reactionary media at the moment, it needs to be clear that healthcare is not a place to be politicised. It should serve everyone in the community. Healthcare if for everyone, it is not a political question, it is a human right. 

KN: Absolutely. And it is becoming harder and harder, as budgets are being squeezed and services are being pushed, to do more and more for less and less. It is harder to keep those kinds of overarching aims in view. You feel like you have to put your head down and get on with it and everything else is treated as an add on but actually, reaching out to minorities is a vital part of the service. 

Who is left out of the conversation when it comes to sexual health?

KN: We have talked about some groups already, but another group is rural populations. The access to care you get in rural Wales is different to what you’ll get in Cardiff. And when trying to access sexual health it can feel very isolated. These communities are no less deserving of good sexual health and access to healthcare as anyone else. 

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RG: I think Wales is doing some positive work on this, like with the Wellbeing of Future Generations Act, but I think that the patients’ voice and co-creation is extremely important too. For people living with HIV we need to have that voice to beat the stigma that exists. Otherwise it is hard for someone within the Welsh NHS, or Public Health Wales to understand, say, what it’s like for someone living with HIV in Powys or further afield 

KN: I have seen how powerful it can be when communities gather together and are given the space and freedom to be able to design and deliver services. I know of people who set up a cervical screening service in Soho for trans people and that was done out of co-creation and partnership and was a great success. We can take those examples of working and implement them in Wales to create something amazing. 

How could sexual health practices be more inclusive in Wales?

RG: I think the biggest risk for us not meeting our 2030 target is some organisations deciding on actions without consulting others, and then within a few years they have lost X amount of thousands and it hasn’t worked, whereas they should have brought people in at the start. Everyone should be treated equally and as people with opinions of equal value, whether that’s a patient, someone living with HIV, to the charity sector to NHS, everyone has to be in that room and have that access and right to be heard and sometimes that’s missed.

KN: It is a worrying situation where people expect things to work the same ways everywhere. That screening service in Soho works really well there because it is co-created by the people living in that area. That doesn’t necessarily mean that it would work here. We have to be responsive to what is happening in our local communities and that the organisations work with these groups, especially minority populations. 

I grew up in the 80s/90s when we had Section 28 and it was illegal to talk about being LGBT in schools, so there was no information out there at all.

RG: It is easy for organisations to say this is how we have always done it and it works fine, but I think healthcare needs constant reinvention depending on the needs of those individuals and that is why you can never take the patient voice for granted. 

What about sexual health research? Could that be more inclusive?

KN: Research is often driven by what can get funded. So if you have money from a large pharmaceutical company relating to a product they are producing then you can create some quality research. It is a lot harder when it comes to reaching out about minority populations, especially when it comes to rare conditions or disadvantaged groups. With the trans community it is hard to be able to find people in the country knowledgeable enough to do that work and at the same time get the backing and money behind that research. In some of my work I feel like I am stepping into unchartered territory. But recently I was doing some teaching at a medical school in Cardiff and I feel optimistic for the future; that we are developing a workforce, particularly in sexual health, who are a lot more in tune to minority populations and aware of diversity and how that interacts with medical care.

Lastly, I wanted to touch on a debate that has risen in recent years. There has been controversy over relationships and sexual education being taught in Welsh schools. What are your thoughts on this? 

KN: I am really glad that the Welsh government has taken a robust view on this and that sexual education is a key part of education for all young people as it should be. It is worrying that there are so many groups out there protesting and creating controversy and spreading misinformation about that education. It is important to educate youths on good sexual health, how to be safe in sex, and how to be proud of your sexuality or gender identity, and I cannot see how people think that is bad for young people. I grew up in the 80s/90s when we had Section 28 and it was illegal to talk about being LGBT in schools, so there was no information out there at all. I think the fact young people can access that information now is wonderful and we need more of it, not less. It would have meant so much for me to have that growing up. 

Sexual health awareness and education is important and vital for everyone. 

All articles published on the welsh agenda are subject to IWA’s disclaimer. If you want to support our work tackling Wales’ key challenges, consider making a donation or becoming a member.

This interview was conducted and edited by Kaja Brown thanks to the Books Council of Wales’ New Audiences Fund.

Kaja Brown is Digital Communications Co-ordinator at Climate Cymru. She is a writer, editor and storyteller interested in society and activism in Wales and beyond. She blogs at thecreativeclimateactivist.com

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