Sexual Health is Mental Health: Developing ACCESS-MH

We need to talk about sex in mental health settings.

In recent years, it has become widely recognised that people living with psychiatric disorders experience a disproportionate burden of preventable physical illness. Research suggests that people with Severe Mental Illness (SMI) die 15-20 years earlier than the general population, with physical health conditions contributing substantially to this mortality gap.

Growing recognition of this inequality has driven efforts to improve the prevention and treatment of cardiovascular disease, diabetes, obesity, and smoking-related illness in psychiatric populations.

But one important area of physical health remains significantly neglected: sexual and reproductive health.

People with SMI have a two- to four-fold increased risk of sexually transmitted infections (STIs) compared with the general population. Uptake of cervical screening (which tests for high-risk strains of HPV that can lead to cervical cancer) is lower among people with SMI, while cervical cancer mortality is higher. Yet research suggests that only around 54% of people with SMI access sexual and reproductive healthcare services. There is therefore a clear disparity in need vs provision.

As a PhD researcher working at the intersection of women’s mental, sexual, and reproductive health, this disparity stood out to me.

In response, I developed ACcess to CErvical and Sexual health Screening in Mental Health settings (ACCESS-MH), bringing together a multidisciplinary team of clinicians, nurses, and researchers alongside gynaecological health technology company Daye to explore a different approach to sexual healthcare within mental health services.

But before I explain what we are doing, it is important to understand why this gap in care exists in the first place.

The Gap in Sexual Healthcare

There is no single explanation for these inequalities: the barriers to accessing adequate sexual healthcare are multiple and interconnected.

At an individual level, mental health symptoms can make it harder to recognise a health need, arrange an appointment or attend screening. Stigma, shame, and fear surrounding sex and sexual healthcare can create further barriers, particularly when procedures are intimate or invasive.

Sexual health is also still surrounded by stigma and embarrassment, meaning patients may feel uncomfortable raising concerns themselves, while clinicians may feel equally uncomfortable asking.

This is especially important given that people with SMI are at greater risk of experiencing sexual violence than the general population, with women disproportionately affected. Cultural and religious factors may also influence how comfortable someone feels discussing sexual health or accessing existing services.

These barriers may be particularly pronounced for some groups. Trans and gender-diverse people can face additional barriers to sexual and reproductive healthcare, including stigma and discrimination, services that are not designed around their needs, and assumptions about their bodies, sexual practices or screening requirements. For trans people who also experience SMI, these barriers may intersect, creating additional challenges in accessing appropriate and affirming care.

But these barriers do not sit solely with patients. In my conversations with clinical staff, discomfort around sexual health has at times been palpable, with many describing a lack of training, knowledge, and confidence in discussing sexual health and sexual healthcare with patients.

And perhaps this reflects a much wider problem. As a society, we are still uncomfortable talking openly about sex. When that discomfort follows us into healthcare, sexual health needs can go unspoken, unasked about and ultimately unmet. Our collective discomfort with talking about sex could be costing our patients their health, and, in some cases, their lives.

There are also significant barriers within services. When someone is acutely mentally unwell, other aspects of their health can understandably fall down the list of immediate clinical priorities.

In inpatient mental health settings, sexual health is not routinely assessed, meaning that identifying a potential infection can depend on either the patient raising it or staff recognising symptoms. Even when a need is identified, screening and treatment are generally provided outside the mental health service, requiring already stretched staff to arrange and coordinate chaperoned appointments at external sexual health clinics. For patients experiencing fluctuating or severe symptoms, and staff working in busy, under-resourced, and often short-staffed services, ensuring timely access to care can be challenging. As a result, important opportunities for screening, treatment, and prevention can be missed.

The consequences can be substantial. Many sexually transmitted infections cause few or no symptoms initially, yet if left undiagnosed and untreated can result in chronic pain, infertility and other serious health complications such as cancers. Delayed diagnosis also creates opportunities for ongoing transmission.

However, mental health services may also offer a unique opportunity to address these inequalities. For many people with SMI, mental health professionals are among their most consistent points of contact with the healthcare system. Rather than expecting people to navigate another disconnected service, could we make sexual healthcare more accessible within the services they already use?

This is the question that led me to develop ACCESS-MH.

What is ACCESS-MH?

ACCESS-MH is an ongoing, co-developed, multidisciplinary implementation study investigating how Daye’s diagnostic tampon could be used within psychiatric services, allowing women and people with a cervix to self-collect a sample that can be tested for HPV and sexually transmitted infections.

Importantly, we are not testing whether the tampon works as a method of collecting samples. The technology has already been developed and demonstrated to effectively collect diagnostic samples. Instead, our question is: how can we implement this technology acceptably, safely, and feasibly within mental healthcare settings?

Self-sampling could remove some of the barriers associated with traditional sexual health screening by giving people greater privacy, autonomy, and control. But an effective technology will only improve healthcare if it can work for the people using it and within the services delivering it.

ACCESS-MH will therefore aim to work across a combination of inpatient and outpatient mental health settings to understand how this approach can be incorporated into real-world psychiatric care.

Where Are We Now?

ACCESS-MH is currently in its protocol-development phase, with co-production guiding every stage of the process.

Central to this is our group of 10 Lived Experience Contributors (LECs), who bring diverse perspectives across age, ethnicity, gender, socioeconomic circumstances, and cultural backgrounds. Through a series of co-production workshops, they are involved in protocol development from start to finish, shaping every major study decision – from which patient groups and clinical settings we prioritise, to recruitment and consent, study procedures, how the diagnostic tampon is introduced, and how results and follow-up care are managed.

Alongside this, I am consulting with up to 30 clinical staff across both inpatient and outpatient mental health services, including nurses, support workers, occupational therapists, psychologists, and psychiatrists. These consultations will allow us to understand the practical realities of delivering the study: what would work within existing clinical pathways, where additional demands might fall on staff, and what barriers need to be addressed before implementation.

Together, these perspectives give us a 360-degree view of implementation, combining the expertise of people who use mental health services with those who deliver them. Our aim is to develop a protocol that is trauma-informed, inclusive, accessible, and scientifically robust, while also being genuinely feasible within busy mental health services. By identifying and addressing barriers before implementation, we hope to develop an approach that works for both patients and clinical teams, and therefore has the potential to create meaningful, sustainable change in access to sexual healthcare.

Illustration by Masantocreative on Unsplash

Looking Beyond ACCESS-MH

More broadly, ACCESS-MH forms part of a bigger question about how we address physical health inequalities in psychiatry.

Identifying inequalities is only the first step. We need to understand the barriers that sustain them, use implementation science to determine what actually works in real-world services, and embrace innovations that can make healthcare easier to access. Crucially, we need to design solutions alongside the people who will use and deliver them, not for them.

For sexual health, this also means normalising conversations about sex. Patients need to feel able to raise sexual health concerns, and clinicians need the confidence to ask about them without embarrassment or shame. Better access will only go so far if we remain uncomfortable having the conversations that enable it.

Achieving genuine, real-world change also requires working across traditional boundaries, bringing together researchers, clinicians, frontline staff, people with lived experience and industry innovators. Each brings a different form of expertise, and none is sufficient in isolation.

The ambition therefore extends beyond ACCESS-MH or any single diagnostic technology. ACCESS-MH is one attempt to demonstrate what can happen when lived experience, clinical expertise, research and innovation come together to design healthcare differently; making sexual healthcare a more accessible, routine and stigma-free part of mental healthcare.

Illustration by Alghozy on Unsplash