Written evidence submitted by Changing Lives [WRH0046]

 

  1. Introduction

1.1.            Changing Lives welcomes the opportunity to submit evidence to the Women and Equalities Committee’s inquiry into women’s reproductive health.

1.2.            Changing Lives is a national charity, helping over 14,000 people change their lives for the better each year. We have around 100 projects in England, supporting people in the most challenging of circumstances including homelessness, addictions, contact with the criminal justice system, sexual exploitation, domestic abuse, long-term unemployment and more.

1.3.            Changing Lives is also the lead partner for the STAGE Project, funded by the National Lottery Community Fund, to provide trauma-informed support to adult women across the North East and Yorkshire who have been groomed for sexual exploitation and build an evidence base around their experiences of accessing justice, healthcare, housing and other forms of support. The STAGE Project brings together Changing Lives and seven other specialist charities – GROW, A Way Out, Together Women, Basis, WomenCentre, Ashiana and The Angelou Centre.

1.4.            Our evidence is drawn from two research briefings produced by the STAGE project which explore the experiences of accessing healthcare amongst women facing sexual exploitation[1][2].

1.5.            Although our research focuses on a specific type of sexual abuse – adult sexual exploitation – the lessons learned for reproductive healthcare could be applied to women who have experienced other forms of sexual abuse and trauma.

  1. Barriers to accessing reproductive healthcare amongst women who have experienced sexual exploitation

2.1.            Gynaecological issues are very common amongst women who are supported by the STAGE project as a result of sexual exploitation, but often the women do not want to or are prevented from accessing support. Data collected from the project in 2022 found that only 20.3% of women supported by STAGE had accessed sexual healthcare within the last year. Reasons given for not engaging included feeling it is not a priority; fears they will be judged or questioned about their circumstances; and, if they have children, fear of repercussions from statutory agencies.

2.2.            For women experiencing sexual exploitation, or indeed other forms of abuse or multiple unmet need, gynaecological and reproductive health is not often a top priority. Women will prioritise immediate and survival needs over their engagement with health services. For this reason, we recommend that reproductive healthcare services proactively engage with these women, including providing outreach services or drop-ins at locations women will be more likely to attend (e.g. women’s centres).

2.3.            Black and minoritised women supported by STAGE are less likely to access sexual healthcare due to it being seen as shameful. For non-English speaking women, describing their symptoms can be difficult as many languages do not have a direct translation when discussing sex, rape, STDs etc. We therefore recommend increased provision of translators and engagement with specialist organisations run by and for Black, minoritised and migrant women who can help with both translation and how to communicate concepts that are difficult to translate.

2.4.            Fear can be a barrier to accessing all forms of healthcare, including reproductive healthcare. This can include fear of judgement, fear of stigma, fear of not being believed, and fear of the treatment itself. This can be compounded by past experiences where healthcare professionals were not trauma-informed in their practice.

2.4.1.       The fear of stigma can be mitigated against by providing specialist services or appointment times. For example, some healthcare services in Leeds offer ‘red umbrella’ appointments. Women can show a red umbrella card or just saw ‘red umbrella’, which discretely identifies them to healthcare staff as someone involved in sex work, allowing them to attend fast-tracked appointments with no difficult questions. Although this does not cover all forms of sexual exploitation, as many women would not identify as sex workers, it can offer targeted support to both those who are being sexually exploited and those consensually selling sex.

2.5.            Women tell us that when they access healthcare there is often a ‘pregnancy focus’ where they are continuously asked questions about pregnancy and feel forced into contraception, regardless of what their initial reason for seeking care was.

2.6.            It can be particularly difficult for women to access reproductive and gynaecological healthcare due to the interaction between these areas of health and sexual exploitation and abuse, and the lack of understanding sometimes shown by medical professionals.

2.6.1.       For example, one 16-year-old sought a sexual health screening during a period of lockdown restrictions and was told by the receptionist that “you shouldn’t be having sex during the pandemic”, without any questions of why this young person might need screening.

2.6.2.       Cervical screening is a procedure that women supported by STAGE commonly find too traumatic. One woman reported that her concerns were not taken seriously when she attended a cervical screening appointment. She was told “you’ve had sex and had children, so why are you bothered about this?” We are particularly concerned about the neglect of this area of health given the increased risk of cervical cancer for women who are introduced to sex/sexual violence at a younger age with multiple partners/perpetrators[3].

2.6.3.       During labour, another woman was laughed at by a midwife and told “I can’t understand how you can engage in sexual activities yet can’t let me check how far dilated you are”.

2.7.            We recommend trauma-informed training for all medical professionals working in reproductive healthcare, particularly given the sensitivities of this type of healthcare.

  1. Opportunities within reproductive healthcare to identify and respond to exploitation and abuse

3.1.            Women who are experiencing sexual exploitation are often mistakenly identified as sex workers. Healthcare staff may be aware that they have multiple sexual partners and treat them accordingly but do not tend to have the training to identify warning signs of exploitation and abuse.

3.2.            Engagement with reproductive healthcare is an opportunity to identify and support women who are experiencing sexual exploitation and other forms of abuse, but we have found that this opportunity is not often taken due to a lack of awareness amongst healthcare staff of the things to look for and where to refer women for support. Professionals often fail to question why women are presenting with multiple unwanted pregnancies and recurrent STDs from multiple partners, despite these being warning signs for sexual exploitation. Rather than asking explorative questions to determine why a pregnancy is unwanted or if a woman is being forced into sex and/or the abortion itself, our experience is that healthcare professionals tend to only focus on contraception as a solution.

3.3.            Reproductive abuse is a form of control used within sexual exploitation. For some, this can mean forced abortions, but for others, more commonly seen amongst Black, minoritised and migrant women, it can take the form of withholding of contraception and forced pregnancies. This latter form of abuse tends to take place within marriages and the pressure to conceive can come not just from the women’s husbands but also their in-laws.

3.4.            We recommend training for reproductive healthcare professionals in recognising warning signs of exploitation and abuse, including discomfort due to diagnosis and treatment procedures, and how to ask questions in a sensitive and trauma-informed manner.

 

September 2023

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[1] STAGE (2022) Experiences of accessing healthcare amongst women who have experienced sexual exploitation. Accessed 1st September 2023: https://changinglives.cdn.prismic.io/changinglives/70b93284-01f2-4625-be23-4b6efc3349d1_Experiences+of+Accessing+Healthcare+-+Jun+22.pdf

[2] STAGE (2021) Experiences of accessing health. Accessed 1st September 2023: https://changinglives.cdn.prismic.io/changinglives/b8caef9f-91c4-43a9-8a51-55e19839b12d_STAGE+Health+Briefing+May+2021.pdf

[3] Louie, K.S, de Sanjose, S et al (2008) Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries. British Journal of Cancer. 100(7): 1191–1197.