Sexual health services in urban, suburban, and rural outpatient mental healthcare settings in New York: findings from a survey of practices and gaps

A recovery orientation, emphasising patient empowerment and self-determination in treating psychiatric disorders, has prompted clinicians and care systems to re-think how they address sexual health among people with serious mental illness, providing an opportunity for mental health organisations to assess unmet need and improve access to these services.^1,2 Serious mental illness refers to conditions consistent with psychosis such as schizophrenia, schizoaffective disorder, and bipolar disorder.³ Accessible care is critical to preventing and treating sexually transmitted infections⁴ and is an equity and social justice issue for populations subject to unfair distributions of healthcare.⁵ Although the vast majority of people in care for serious mental illness consider a supportive relationship that is emotionally or sexually intimate to be a key facilitator of recovery, only a small minority are in such relationships and numerous barriers to intimate relationships have been described,⁶ including mental health treatment programs, themselves.⁷ The extent to which programs offer their patients even basic sexual health assessments or education is not well described.^8–10

For a training program funded by the U.S. Health Resources and Services Administration, an annual needs assessment questionnaire was sent to directors of all licensed outpatient mental healthcare programs in New York state seeking information about program characteristics, sexual health services offered, and provider training needs related to patient sexual health. Programs were contacted through an e-mail distribution list of 434 clinical directors provided by the New York State Office of Mental Health, followed by two e-mail reminders over 3 months. Responses were anonymous, but e-mail bouncebacks suggested that some programs had closed or had been absorbed by larger programs; some large programs with multiple sites responded with one survey; and 11 programs were not contacted because of disqualifying factors. A total of 132 surveys (Qualtrics, Provo, UT, USA) were completed; removing the 11 disqualified programs, the response rate was 31%, consistent with online survey response rates.¹¹

Among respondents, 72 (54.6%) were in urban areas, 28 (21.2%) in suburban areas, and 32 (24.2%) in rural areas. A majority of agencies (n = 65, 49.2%) served more than 1000 patients, whereas 22 (16.7%) served 200 or fewer. Most agencies (n = 81, 81.8%) reported that sexual health services were essential or very important for their patients. However, across settings, gaps in sexual health services were observed, particularly with respect to processes for knowing whether patients were sexually active, engaging in sexual behaviours that put their health at risk, and in need of HIV testing and pre-exposure prophylaxis. Staff training in sexual health services delivery was reported as being needed by 52 (51.5%) agencies. Thirty-eight agencies (38.0%) were not distributing condoms. Table 1 shows characteristics of these agencies and the sexual health services they were providing by location, with significant differences found for sexually transmitted infection (STI) screening, sexual health education, condom distribution, and barriers to condom distribution.

Mental healthcare agencies in urban regions were better equipped to provide optimal sexual health services on-site than rural agencies. Also in rural areas, barriers to services (i.e. condom distribution) were predominantly reported to be due to either lack of funding or lack of need, whereas in suburban regions the top barriers cited were lack of need and policy proscription (not related to any religious affiliation of the agency).

Consistent with prior research, we found that healthcare access depends on geography.¹² To improve sexual health services available to people with serious mental illness, a population overlooked and underserved, we must develop evidence about their sexual health service needs. Even in resource-constrained settings, improving staff awareness of resources and their capacity to deliver sexual health services is possible.

Data availability

The data that support this study will be shared upon reasonable request to the corresponding author.

Conflicts of interest

The authors declare no conflicts of interest.

Declaration of funding

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U1OHA29291) with zero percentage financed with nongovernmental sources. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.