Can mainstream services learn from male only sexual health pilot projects?
- Correspondence to: J Hancock I Barrington Court, Colney Hatch Lane, Muswell Hill, London N10 1QG, UK;
- Accepted 9 September 2004
Over the past decade a number of community based sexual health projects aimed solely at young men have proved to be very successful at attracting young men into genitourinary medicine services. These projects are often short term funded and under evaluated so it isn’t clear exactly how successful they are and why this might be so. These projects should be carefully evaluated and examined to elicit factors, either unique or common in nature, which could be utilised by mainstream sexual health services wishing to develop work with young men. There are many barriers to this happening in mainstream services, some being resource and time problems and others to do with values of staff and lack of quality training. The article looks at practical ways that working with men and the skills and confidence of staff can be improved in mainstream settings while recognising that much of what needs to be done to support the needs of young men must take place in the planning and commissioning stage of services.
Despite increases in the 1990s, the number of young men attending sexual health services for condoms and preventative advice about safer sex remains very low.1 While genitourinary medicine (GUM) services across the country attract roughly equal numbers of men and women research suggests that this is overwhelmingly down to male clients requesting screening.1
It is thought that the reason for such poor attendance is a combination of young men’s perceptions of sexual health services as being for women (and that seeking help is “unmanly”) and many services being unable (and sometimes unwilling) to work effectively with young men.
Some mainstream sexual health services have been able to offer preventative services that are more male friendly and have seen a concomitant increase in young men attending.2
An increasingly popular (although underevaluated3) method of addressing the needs of young men has been to commission community based outreach services that specifically offer a preventative sexual health service for boys and young men. This paper will examine the work of two of the more established projects in this area; the male only sessions at Wirral Brook,4 which has the highest proportion if young men attending its services within the Brook clinic network, and “The Spaceman” projects established in Derby by the author in 2000.5
Some of the learning of these specialist projects will be reviewed and then some of the factors preventing incorporation of similar practices into mainstream clinical services will be discussed. The paper will end with some recommendations about how this might be achieved with a greater number of mainstream services.
MALE ONLY SEXUAL HEALTH SERVICES
The male only sessions at Brook Wirral and the “The Spaceman” projects in Derby have been running since 1998 and 2000 respectively. They found that young men wanted access to free condoms and confidential information but that they were unwilling to access these from mainstream sexual health services. Consequently specific services were set up to run once a week for around 2 hours. Both services initially were set up in city centre locations—the Brook service ran in their main centre in Birkenhead and “The Spaceman” ran at a young people’s information and advice centre called “The Space.” “The Spaceman” rolled out further satellite projects into specific areas of the city where the workers perceived there to be further issues around access to the city centre service.
Both services became very popular with large numbers of boys and young men. Brook Wirral has the highest proportion of young men attending its services within the Brook clinic network, and the city centre “The Spaceman” project has had over 1000 visits since November 2000. Perhaps, more importantly, these young men have not just received condoms but have had the opportunity to gain more knowledge about sexual health as well as being given a safe space to discuss concerns they may have around puberty, penis size, masturbation, relationships, STIs, and testicular cancer (among other things).
This section will examine some of the successful strategies they have employed and some other important themes that the work has raised, including the limitations of the service.
Emphasis on promotional work
Because of the prevailing view of sexual health services as being for women these projects have to put a lot of effort into promoting their service as being for men. This has been done in a variety of ways.
Sustained attempts to deliver male focused sex and relationships education (SRE) have often proved successful in encouraging young men to attend services. Both the Spaceman and Wirral Brook service use the project workers to deliver SRE so that young men know what they are getting when they go to the service. The Derby team found that good quality SRE was important, often using resources like “Strides”6 and then testing and creating their own resources.
The Derby team have also been inspired by projects such as “Alive and Kicking” and “Twilight Football” that thought laterally about where young men were (by targeting young men through sporting projects).4 This led to young men being targeted in workplaces (like Rolls Royce and Derby County), hostels, and sports projects as well as schools, youth clubs, and colleges.
Targeting approaches that are men focused
The Derby “Spaceman” project uses promotional material that very specifically includes young men and also uses “cheeky” humour (fig 1). A new version of BAM (Brook and Men) in south west London uses a comic book style graphic (fig 2).
Several male only sexual health services have reported that word of mouth is a key promotional tool in encouraging young men to attend them. This, coupled with the above outreach approaches, can take some time to bear fruit.3
Emphasis on having youth/outreach workers
Youth workers (or outreach workers with youth work skills) often staff these projects, including the consultation element. They are can be well equipped to deliver the educative service that young men want and are able to reassure clients over their wariness attached to accessing mainstream services.
There is a debate about the importance of male workers doing sexual health work with young men. Although most male sexual health sessions have male workers there isn’t evidence from young men that this is what they want. In “Boys’ and Young Men’s Health: What Works?” Trefor Lloyd concludes that gender isn’t necessarily a qualification.7 Indeed, early versions of the young men’s sexual health work in Derby were staffed entirely by female staff
Having male workers can present an image that the service is male friendly, but having the skills, confidence and positive attitude about young men is seen as more important.
Working towards a positive framework of masculinity
Many mainstream sexual health services have views of young men that they are irresponsible and predatory and generally find it difficult to be positive this group. In relation to making space for young men in family planning clinics, John Seex wrote “…young men are viewed as oppressive and needing to be controlled.”8
Many projects that work well with young men have a positive attitude towards them. This isn’t to say that these workers collude with oppressive views around women and homosexual men; on the contrary workers develop an understanding of where these views come from and are often able to challenge them constructively. They are also likely to look at the underlying causes of disruptive behaviour9 of young men and to look at their own practice of what they do which may be the cause of this.
A preventative approach
Male sexual health projects tend to focus on a preventative approach relying on information, advice, and signposting. There has been a youth work approach in these projects that not only provides a safe and confidential space for young men but also an informal educational element that is very important. The following methods have been used in developing this approach.
“Free and funky” condoms
Youth workers have been able to give away free condoms to young men so long as the Fraser guidance is followed for young men under 16.10 It has been established as good practice to make sure that the clients know how to use the condoms when first given them. To encourage young men to use condoms these projects have used a broad range of condoms (flavours, different sizes, and thicknesses, etc). This has been a major marketing tool in bringing young men in and it shows that the service cares about the sexual health needs of young men. It is sometimes easy to forget that young women have a broad range of contraceptives types and brands from which to choose. Young men sometimes only have a choice of two or three different kinds of condom that often come in one size only.
“Bite size chunks” of information
Both the Wirral and Derby projects have used an informal programme offering “bite size chunks” of information. Both projects saw that condoms had to be made easily available but that there needed to be some way for clients to identify their own sexual health needs. This has meant that in each consultation the clients are offered some information on a particular topic (for example, emergency contraception, STIs, testicular self examination, local services, sexual anatomy, etc), which could be in the form of a leaflet that is popped into a condom bag or an informal discussion, depending on the client’s needs.
These projects put a lot of emphasis on a youth work approach with clients where trusting working relationships are built. Use of a “bite size chunks” approach and a reinforcement of the confidentiality policy often meant that the client felt more comfortable asking about a specific problem, wanting to learn more about sex and sexuality, and admitting their lack of knowledge. Project workers have reported on a number of occasions that clients come back ostensibly to get more condoms but actually to get more information and to take advantage of being able to talk openly and safely.5
Limitations of this approach
Much of the apparent success of these projects is because they have specific funding and allocated time to work specifically with young men. This has enabled the project workers to be flexible and client led and can offer a level of service that mainstream services would struggle to match. So the temptation for many areas is to develop their own male sexual health services in order to meet the needs of young men.
However there are some problems with this. These projects are rarely core funded (the Derby projects face an ongoing funding struggle) which means that they usually can only offer a temporary solution. Additionally, the skills of these project workers are seen to be so esoteric that mainstream services think that this kind of work is something that only youth workers (especially male youth workers) can do.
While these projects provide an excellent service that could be copied around the United Kingdom, it would only be able to offer this for a limited number of hours per week. To prevent boys and young men work from being seen as a specialist add-on mainstream services need to learn from some of the lessons of these projects and to try and fit them into every day practice.
DIFFICULTIES IN MAINSTREAMING THE LEARNING FROM SPECIALIST PROJECTS
Reproductive and sexual health services face many problems in working with young men in mainstream “mixed settings.” Some key factors underlying these problems, based on both published research and the author’s own experience of training mainstream staff, are outlined below.
Insufficient space or time
Young men like to attend sexual health services in groups and there is often a problem with finding sufficient space for them to sit in. Young people’s clinics especially are often very busy with lots of young women in the waiting area. Also there is often a long waiting time to be seen. Young men can become impatient waiting for something that they see as easily accessible. Additionally, clinic rooms are unlikely to be the right size for group work so boys might be seen in ones or twos, lengthening their waiting time.
“The Spaceman” projects have been able to offer settings that are for the exclusive use of their clients with large comfortable waiting rooms that are made “male friendly” with appropriate magazines, TV, and music. Additionally, because of the skills of the workers there is no problem with a large group of friends wishing to be seen at the same time—this has a beneficial effect on the waiting time for clients.
Disruptive or oppressive behaviour
On many occasions, probably related to the above, young men in groups can be intimidating for staff unused to working with groups of young men.8 For example, within space limited male only waiting areas at GUM clinics, young men often prefer to walk around rather than sit still. Such activity may be misinterpreted as aggressive behaviour by staff whereas this behaviour may reflect underlying embarrassment and insecurities, counteracted by a “macho” display to peers.
Additionally young men can display inappropriate behaviour towards female clients and female members of staff. Although the causes of this behaviour might be explained by underlying embarrassment and the broader socialisation of men this can be very difficult for members of staff to deal with.
Lack of desire for a clinical service
Unless young men are attending a service for a clinical reason (for example, infection screening) and just want to obtain condoms and information they are often unwilling to go through the procedure of the registration/triage. Young men are often very wary of giving too many details to a service because of their concerns around confidentiality. They also often have concerns over how long the process takes. This often means that male clients are not prepared to take the risk and invest the time required to see someone in a mainstream service because they don’t feel that the service they are requesting warrants this.
This can result in young men not seeing a health professional and perhaps settling for some condoms from the reception area. With younger clients this can result in visits that are chaotic, resulting in disruptive behaviour with condoms used as balloons and leaflets left littering the entrance.2
Non-attendance at clinical services
As mainstream services do not attract large numbers of young men, these services may not be able to justify spending money on extra resources to address the needs of young men. This could confirm stereotypes for many that men are irresponsible because they don’t come in (and then when they do come in they display disruptive behaviour).8 This creates a vicious circle where if a service is not promoted and geared to young men then they will not attend, if young men do not attend then justification for further funding may not be seen.
There are examples of mainstream services working towards addressing the needs of young men2 and GUM services are well placed to provide excellent preventative services for young men. Many services have male and female waiting areas, male members of staff, access to condoms, and access expertise on health issues that men have concerns about (sexual problems, penis and testicular problems, and STIs).
Promoting the service specifically targeting young men
Something that all mainstream services and partnerships could do easily is to take on board some of the learning to promote what they offer. This could involve asking young men about the design of promotional material and thinking of original approaches to where to promote their service.
It is important to make sure that services don’t just say that they are male friendly without actually reflecting on how to make changes in their service.11 The male only projects have used a broad range of condoms to promote their service. Limited funding means that clinics often have to bulk-buy a limited range of condoms. These limited ranges of condoms could be supplemented by a small number of flavoured and ribbed condoms. Although if services can ever truly strive to address the sexual health needs of men greater choice of free condoms needs to be available at all mainstream clinics.
Having the right workers
As noted earlier gender is not necessarily a qualification to working with young men around sexual health. Young men are far more concerned that members of staff are positive about them and that the staff know their stuff. A key skill highlighted by John Seex is the ability to deal with potentially boisterous or challenging behaviour.8
There is an art in being able to inform young men of acceptable behaviour in a clinic while still retaining welcoming body language. There are probably some members of staff better at dealing with this than others but often there is an assumption that unless they are male they will not be any good at it. It is also something that could be practised and it is also a skill that any good youth worker can pass on. Services that are able to establish links with local youth projects may be able to “borrow” a worker or attend joint training in exchange for sexual health training or outreach visits.
As the skills of reception and information workers are much more commensurate with that of youth work than reception work, perhaps this is something that could be explored when recruiting to reception positions in mainstream sexual health departments
Offering information and easier access to condoms
To cut down on the amount of time that is needed to give young men what they want the registration and triage process for young men (and young women) just wanting condoms and information could be made a lot simpler and quicker. Many of the male sexual health projects have cut down the amount of information they need to a bare minimum—for example, taking a first name, ethnic origin, age, area code, and where they heard about the service.
A system of fasttracking could be used for those men simply wishing to receive condoms, perhaps combined with self triage on arrival at the service to indicate requirements from the service. Willing receptionists could also be trained to demonstrate condom use to young men accessing the service for the first time
Overcoming time and space problems
A number of services have separate entrances for males and females, which would help to overcome many of the problems outlined earlier or two waiting areas, which could informally be used for young men attending a clinic on their own. Where available group work rooms or “health education rooms” could be booked out for times when large number of young men might attend.
If this is not possible, creative thinking around working practices and resources could help overcome space limitations. For example, in most clinics there are times of the week that are very busy with young women, there might be other times of the week where men might have more space—this could be promoted.
Another tactic (although not ideal) is just to be honest with young men if the clinic is very busy and advise them about when it may be better to return and the potential benefits for them returning at that time.
Some of the above strategies are relatively easy to implement; however, without services feeling positive about young men this would all be irrelevant. Key to working with young men is the establishment of a positive attitude towards them by all clinic staff. This is especially important for reception staff who provide the front line “face” of most services.
Many workers in this field will positively dislike working with young men. I have delivered and participated in training where participants (both men and women) have conceded that they feel very negative about men in general. Staff in sexual health clinics will have worked with many people who have been victims of male oppression; rape victims, victims of homophobic attacks, young mothers left to fend for themselves. Indeed much of the contraceptive service model has been built with the values of female empowerment in mind but it is important to distinguish between the struggle for equal rights for women in a patriarchal society and the view that “all men are bastards!”
This is where good quality training is vital. Participants feel able to explore their own values and where they come from, without the feeling that they are being blamed, in order to be able to understand the concept of a positive framework of masculinity. Services that work towards understanding this will be infinitely better equipped to come up with their own strategies for working with young men.
Although it seems obvious that mainstream clinical services need to be able to work with young men more effectively (given that they are 50% of the potential target group), there are no easy solutions to be able to meet the sometimes competing needs of young women and young men.
In the meantime, a dual approach is probably needed where specialist male only sexual health services are run alongside mainstream services, either within the same space or in outreach settings. Male only sexual health services need to be correctly evaluated, preferably by an external source, so that we have a clearer picture of how they work well as models of good practice, how cost effective they are, and what are their limitations. Clinic staff also need to explore ways in which they can offer a more holistic mainstream service catering for needs of young men and obtain training and support to enable this to happen.
The author works for Brook London as an outreach worker and freelance as a consultant and trainer.
For further information about the Derby projects please contact Diane Marriott, Specialist Youth Team Leader, Derby City Council, Youth House, Derby DE1 1DY, UK.