My trip to Victoria two years ago to attend my first SexRurality conference in Lancefield was invaluable. It took me out of my bubble here in the West and reassured me that there were clinicians, practitioners and researchers experiencing similar frustrations; eager to find solutions to common issues and struggling under the constraints of the rural sexual health sector. I was so excited to head back to Victoria; back to SexRurality and in some ways, back to my people this year in Creswick.
Creswick. Beautiful Creswick.
Where the hell is Creswick, you ask? You and everyone I spoke to about SexRurality before I left. The look of utter confusion on everyone’s faces reassured me that I was heading to the right place. What better setting for rural health focussed conferences than towns that no-one knows about? Or has driven through once on their way to somewhere bigger and better. Creswick was perfect.
Day one: Get political, get connected
Creswick is found on Dja Dja Warrung land, and Rick Kerr was charged with Welcoming us to these lands. Rick is an Elder and a direct descendant of Leonard Kerr, a Dja Dja Warrung man born at Mount Hope in 1854. He spoke to us about the dreaming stories of the area: of Bunjil Dreaming and the actions of the Raven, the Cockatoo and the Rainbow Serpent. Rick spoke of the passing of knowledge and learning through the ages; how the Dja Dja Warrung “danced their stories in to the fire”. We were welcomed to this country – and ready to begin.
Marie Bubnic provided the conference opening on behalf of the Department of Health and Human Services (VIC) and highlighted the number of demand pressures that are felt within sexual health and reproductive health services provision.
There was an acknowledgement of something that rural workers and researchers understand intimately: that rural service provision is often personnel and personality-based. The doctor in a rural town impacts on what services are available. Marie also spoke about how there was a lack of service integration, and that while cost and travel are significant barriers, the Department had found that rural people are more than willing to travel for services that are inclusive and de-stigmatised.
There was also recognition that current funding and structures are focussed primarily on specialist service provision, and that a transition to more place-based primary care was a challenge that will require collaboration with the sexual health workforce. A subtle plug that Health Promotion must be considered within this attempt to reorientate health services is inserted here.
Kylie Stephens, the Senior Health Promotion Manager at CERSH, gave us an update on what was happening in their world, what they were proud of and the areas CERSH needed to pay attention. Kylie discussed the potential to increase the geographical reach of CERSH while also ensuring that we, as the rural sexual health workforce, continue in our efforts to broaden the responsibility of prevention efforts.
In settings where resources and power are contested, there is a need to ensure that rural voices are provided and heard – and that localised solutions and community participation are important in the rural setting. Kylie also highlighted the need to address workplace attitudes and cultures: practitioners and workers learn that sexual health lacks priority and focus from their peers. So much of this overview resonated with me that it pretty much reinforced why travelling across the country was such a good idea this time, and last time.
Next person to take the lectern was Fiona Patten MLC. Now this isn’t your usual local member address. As the Member for Northern Metropolitan Region in the Victorian Parliament’s Legislative Council, Fiona has been called “Australia’s most effective legislator.” Her legislative achievements put many of our far longer serving elected representatives to shame and her ability to hold us as a crowd was very impressive as she talked about “How do we get politicians to say the ‘S’ word?”
Fiona talked about her engagement with politics before becoming elected and how she went about engaging politicians in ways that aren’t possible now. Fiona spoke of a time when politicians were brave, such as attending a sausage sizzle at a brothel for Open Brothel Day when it coincided with Safe Oral Sex Day. I fear those days are gone. It was also highlighted that sex workers have a strong role in sexual health promotion as educators and should be respected as a resource.
Fiona highlighted what we know: access, stigma and confidentiality are key determinants underlying rural sexual and reproductive health. Now, just because we know it – it doesn’t mean it isn’t nice to hear someone else acknowledge it. It also flowed in to one of the key takeaway points for me from SexRurality 2019: that we need to talk to our politicians about sex – before they start talking about it. And we, the 150+ people in the room were a clear directive and call to action: go talk to our politicians. Talk to them about the issues in our local areas. Tell them our stories. Go with actions and solutions. We are excellent sexual health communicators doing the best that we can – so we need our politicians on OUR side, advocating and lobbying for OUR needs. They can’t do that if we don’t communicate with them.
“Talk sex to your politicians.”
Go to them. Tell them your stories from the field.Go with action and solutions.
Next up, was Associate Professor Christopher Fisher from the Australian research Centre in Sex, Health and Society giving us some rural focussed findings from the 6th National Survey of Secondary Students and Adolescent Sexual Health (research protocol here).
It was brilliant to get the rural focus on these findings and it generated a lot of discussion on why some things were seen in the data. Rural young people were more confident in using sexual health services – and somewhat more trusting. This is something I’ve seen within my own research, where young people did not feel the same level of anxiety over confidentiality concerns accessing rural GPs as the rural GPs themselves felt.
Young people wanted relationships and sexuality education that was real and useful. They did not want tokenism. Findings highlighted the massive burden that young women bear in terms of provision of informal relationship and sexuality education. It’s great that peers are seen as one of the best places to turn to for advice – but how are we supporting these peers?
We then broke for what seemed like the first of several hundred meal breaks and our first real chance to network. I’d been beating off a sore throat for a few days before travelling and was seriously worried I’d lose my voice before I presented on the second day – but there were far too many people to catch up with and talk to. Oh, and some networking of course.
We came back from break to a panel discussion facilitated by Yumi Stynes, the host of one of the best podcasts going around (go listen to it now!). I think Yumi is pretty cool and I can safely report that I (and a few dozen other delegates) totally kept it together after lunch and didn’t descend into pools of pathetic fan-boy/fan-girl/fan-nb behaviour.
Anyway, cart before the horse – before I embarrassed myself, Yumi facilitated one of the most diverse panels I’ve ever seen at a conference. I don’t want to list the ways in which this was achieved in some diversity checklist/shopping list – but let’s just say there were a lot of boxes ticked and a lot of amazing perspectives.
The thing that hit me very early on in the discussion was how a number of the panellists had been failed by their health professionals when seeking help. From a young trans-person being told they were insane, to a pregnant women with genital mutilation being met with overt fear and stigma, to terrible management of a new HIV diagnosis.
The panel was incredibly brave in what they shared with us and were candid in their responses. Yumi asked the panel what they would like to see included in relationships and sexuality education in schools: they were queer inclusivity, pleasure, abortion, understandings about cultural sensitivities, respect, the need to love yourself first. Nothing shocking – but enough to send a politician scared of gender whisperers into a tizz no doubt. These are not the political times of brothel sausage sizzles.
In closing remarks, Yumi encouraged us to get out there and consider podcasting to communicate what we are up to. Expect a heap of sexual health podcasts coming your way – hell, one even popped out of here! We then broke again for food, the chance to network, and the chance to embarrass ourselves at the feet of Yumi. We launched at those three opportunities with gusto.
After food, we started the first of the split sessions. Conferences always present dilemmas on who to see; who to miss. It brings me back to my early days going to festivals when I would scorn the organisers for putting Machine Gun Fellatio and Shihad against each other. Do I choose provocative on-stage antics or power rock?
Now, I’m not going to say which one was which, I’ll leave that to your interpretation – but I started in the Open Topics stream with Shannon Hill and Siobhan Bourke, before racing across the
festival conference to the Place-Based Stream to catch Amy Isham, Cath Tischler and Bernadette Lewis.
Shannon Hill started with a strong question asking ‘What good intention we could put out in our work and make come back to us?’ before presenting on the great work that Women’s Health Grampians had done in developing a Theory of Change – a pathway towards a vision. The Theory of Change was about plotting the way to achieve the vision clearer, thus creating supportive environments and setting foundations for future progress. I liked it. Siobhan Bourke gave a great overview of the Sensitive Physical Examination Program used to teach medical students how to negotiate sensitive examinations. Consent and feedback are key components that students learn – as well as important feedback on body language and how they interact with patients. There was also the great point that we presume medical and nursing students have had great relationships and sexuality education in the past – when often they haven’t.
Across town, Amy Isham and Cathy Tischler gave an overview of how their ethnographic research is embedded alongside (under?) an active participatory action research project to provide deeper understanding of the issues relating to social service delivery and access faced by teenage parents in Horsham. Another great example of regional researchers in a regional area finding local solutions to problems – that will no doubt have value to the wider population. They highlighted the need to address the gaps and ensure that the real world practitioners know as reality is expressed within the research literature. One point Cathy made that ties back to Fiona Patten’s call to action was that politics influences health at all levels and there is a need to empower our regions as a whole. Bernadette Fraser rounded out the session giving an overview of the Storylines project – a collaborative project that gathered women’s lived experiences that highlighted intersections between social determinants, health inequities and barriers to access.
After lunch, Edwina Jachimowicz, a fellow out-of-towner presented on a program that SHINE SA had implemented to build workforce capacity within the rural and regional workforce. The project came about from the knowledge that the sexual health workforce is expected to do as much, if not more as before, with the same or less resources. This brought about the need for a partnership approach. This involved negotiating some turf wars and managing expectations but led to considerable knowledge gains. Next up was Jenny O’Connor from CERSH, talking about working with LGAs in trying to install condom vending machines. Now this is something I know about from my area – I’ve been laughed at for suggesting condom vending machines in our area – and as a Councillor as well as a Health Promotion worker, Jenny has a foot in both camps. Navigating very local politics still needs advocacy, nuance and hard work.
Dr Tim Staunton Smith presented a really nice project on the physically-visible and Web search-able signs that rural GP practices are LGBTQI friendly. It was not the most complicated study – but it did what it was designed to do and I’d love to replicate it here in rural WA. Interestingly, in the days after the conference while in Hamilton, I noted several shops and cafes had Rainbow Flag stickers on their doors. It was subtle. It was simple. I don’t know anything about it – if it’s a local scheme – let me know.
And well – from there, I tapped out for the final 30 minutes and found somewhere quiet to gather myself. Conferences can be really full-on – and with an evening drama performance and dinner ahead – I needed a quiet moment. It wasn’t quite a Bex and a lay-down, but it was close. I followed the Twitter hashtag as I rested, and was again reminded of how useful Twitter can be. Yeah, it can be a waste of time – but #sexrurality was trending locally. I had a heap of interactions from both people at the conference and around the place, and I knew when I got home to write this there would be something to work with. About five years ago, I wrote a little thing for Croakey blog after the PHAA Conference in Perth about joining Twitter. Have a read and a think if you are still to be convinced.
Before we were unleashed on the conference buffet, we were treated to an early showing of ILBIJERRI Theatre Company’s VIRAL. Director Kamarra Bell-Wykes reminded us that the cast were still in the early days of settling into rehearsal and not quite ‘show ready’ – and for us to be kind. This was more of an open rehearsal than a full show.
What followed was gritty, stark and determined story-telling that delved into the realities of health care access, discrimination and colonisation, and the ongoing impacts on the social determinants of health. The sharp and witty dialogue was often split across the three performers (Jessie Butler, Shannon Hood & Nikita Tabuteau) to create power in shared messaging.
It was a raw performance – but a fantastic one. It was great theatre and wonderful to see art and health coming together. Since the last Sexrurality, I’ve gone on a bit of an accidental arts/dance adventure and I think we need to work harder to find synergies between the arts and health – both in terms of messaging, but also advocacy and sharing of ideas and resources.
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Day two: Research, presentations and farewells
I awoke as fresh as a daisy and ready to take on what was going to be another big day of rural sexual health. Today was game day for me – and I could not have asked for a better preparation. It was time to get caffeinated, get excited, warm up our Twitter fingers and get back into it.
Associate Professor Eric Chow kicked off the day with what was new in Gonorrhoea control. This was a pretty epic presentation that I’m not sure I can wrap up that easily. From the question of “Can you use saliva as lube for anal sex?” (You can, but should you? The prevalence of gonorrhoea in MSM who did use saliva was greater than 2 times the prevalence in those who didn’t), to exploring if mouthwash can be a novel treatment for oropharangeal gonorrhoea (or dandruff*) – there was a lot of content covered. What is clear, is that with gonorrhoea on the rise – we need to pay more attention to some of the unrecognised risk factors in transmission.
Professor Jane Hocking was next with a focus on Chlamydia Control. Jane asked us about our current practice and if it was evidence based – our focus tends to be on promoting increased testing – however, this doesn’t necessarily reduce the incidence of Chlamydia and ultimately we want to prevent Pelvic Inflammatory Disease. But PID isn’t monitored. Perhaps we need more of a case management approach to reduce reproductive morbidity and minimise reinfection.
Also, with rectal Chlamydia being detected at increased rates in women – is it something to worry about? Literature shows there is 32 fold incidence in women testing positive rectal infection with urogenital infection. Contamination? Problem? Auto-inoculation? Its unclear. What is clear though, is that Chlamydia vaccine development needs to be a priority if we want to effectively control Chlamydia at population level
Dr Kathryn Cook started off telling us about St Denis, who I have to say, sounded a little bit like a late night conference delegate. St Denis was beheaded. Refused to die. Walked off carrying his head. Then died. And is the patron saint of syphilis. We all reach different heights. As wild as this was – Kathryn wanted to remind us that Syphilis is NOT history. We need to be kind contact tracing, we need to be diligent, we need to understand that even “nice ladies” that got to private clinics for IVF might have STIs. Congenital syphilis is not to be messed with.
After the break and just one more cake, I swear, Anne Roseman hit the stage with an intro song (I wanted my own stage entry song) to talk about Aboriginal Community Controlled Health Organisations and the work they are doing in sexual health. We also heard from Belinda Payne, Tara Purcell and Peter Wapoles-Crowe on their perspectives, involvement and insights. They highlighted that there are thousands of things to be done and sexual health is just one of them. There is under-reporting of STIs – most likely due to stigma and shame – and that universal screening is the key to reducing that shame. ACCHOs are also better placed to do holistic health care – but the FTE provided for sexual health is ridiculously low. Also, being aware of the intersections of gender, sexuality and culture cannot be ignored.
We then got more art in our face with the hilarious Alyce Fisher. It started with dancing condoms and ended with the charming word smith, Cameron. Again. Art. Health. Together. So happy. And safe:
Before lunch, we split again. Some went and engaged with the MoCCA Project as they ran a session about strengthening Chlamydia management in general practice; while the attention-seekers of the conference headed across to participate in an interactive creative development theatre session with ILBIJERRI. No guessing where I went. We worked hard in the theatre group, and all tried our hardest to be respectful of other people’s creative ideas when ours were clearly better, and came together to produce some really pleasing and thought-providing images through our dramatic staging. I hope ILBIJERRI got half as much out of it as we did.
There was time for one last buffet onslaught before the final split sessions – rural research and abortion care in the rural setting. I was at the research stage for that full set – so apologies for the lack of abortion care round up – but I was able to catch Pamela Doherty, from Children By Choice (another out of stater) talking about the barriers and facilitators that were faced in delivery of Medical Termination of Pregnancy (MTOP) in rural and remote Queensland.
Marieke Dam presented the comprehensive approach taken from Women’s Health Grampians within their Increasing Reproductive Choices project. This was a great example of how you must address multiple socio-ecological and service levels to be effective – your approach must encapsulate top-to-bottom. It starts with the public facing front: it’s important that health centre reception staff have training in how to handle inquiries about accessing MTOP. Something I found fascinating a couple of days after the conference, while on a tour of the Budj Bim National Park, was learning that the Gunditjmara people had used green kangaroo apples to terminate unwanted pregnancies. This was normally when there were incoming harsh seasons and there would be pressure on group in terms of nutrition and health. It seems MTOP has been happening in rural Victoria, on country for a very long time.
Dr Cameryn Garrett delivered on the impact evaluation of nurse and midwife contraceptive training. A lack of a Medicare rebate and supportive policies and procedures are barriers to nurses being able to insert contraceptive implants, and must be addressed – regardless of the training. Lily Claringbold presented on research into the factors influencing young women’s contraceptive choices, with fear relating to side-effects and pain, and invasiveness as major potential barriers for the low LARC uptake. Overall, there were many reasons women choose to use a particular contraceptive method, beyond contraceptive effectiveness, and they often make these decisions before speaking to their GP.
Is was then my turn to speak on how I accidentally became a PhD candidate how I got over-involved as a volunteer in trying to solve some sexual health problems within my own community. I was lucky enough to deliver effectively two presentations: one on the Delphi methodology that I utilised to validate the framework for sexual health provision in the rural area, and the second on the four key factors that the framework suggests. I realised as I hit the lectern that there was no presenter’s screen for me to look at – and as someone that tends to use the slides as prompts, rather than write a presentation – it made things a little trickier. Oops. Few tense moments.
Fundamentally, the presented framework suggest four key pillars for rural sexual health promotion from the research: we need to be providing credible and consistent relationships and sexuality education to our young people; ensuring that health services are well-connected and accessible; making sure condoms are easy to get and if possible – free; and building collaborative networks amongst traditional and non-traditional youth sexual health stakeholders. In many ways, it’s what people on the ground already know and do day-to-day. This project was about providing evidence, structure and guidance – not just pointing out what should be done. Hopefully it’s useful.
Anna Roberts presented some more exceptional rural research done by rural people explaining their project’s focus on mapping access to emergency contraception and MTOP – not just in terms of pure service access- but also availability or restriction of medication. Madeline Lim then presented about the artist formerly known as the Condom Fairy: a project that saw university students delivered free condoms on campus. The Condom Fairy was ranked the most convenient way for students to access condoms, and has been since renamed the Safer Sex Program. Finally, Jess Wynn brought us home with her research project asking “Do patients prefer a male or female urologist?” The thing that really resonated with me was that patient preferences are dynamic and open to change – a positive interaction has the potential to alter previous considerations. In my previous life as a nurse that happens to be a male, I would suggest that this research replicates my lived experience.
There were some fantastic presentations this year at SexRurality, but one of the best things about this conference is the collegiality. People want to chat, they want to find out what you do and they want to share what they are doing. It’s an environment of support, encouragement and collaboration. Last time I attended, it was a real boost to my PhD in terms of validating what I was doing and reassuring me that people actually did care. This time around was a similar sense of validation and support – and I always speak highly of SexRurality to my WA-based colleagues. We just need a few more to come next time.
In the days after SexRurality, while driving around rural Victoria checking out the Ballarat’s St Patrick’s Cathedral (timely), Grampians (amazing) and Budj Bim (incredible) – I reflected on the wrap-ups. So many fantastic points – but what was my take away? It took me until the flight home to settle, but I really agreed with Shannon Hill’s presentation and Jenny O’Connor’s interpretation of it during the wrap-up. I then kept reflecting on Fiona Patten’s call to action to engage our politicians. Finally, from the research stream, I agreed with Meredith Temple-Smith’s summation of the session – the need for strategic change.
My take away from SexRurality in 2019 is that we need a clear vision for rural sexual and reproductive health. A vision that includes strategically broadening the responsibility of prevention efforts beyond traditional stakeholders and fostering collaboration while championing reform to policy and appropriate resource provision. There are thousands of things to do, too few people and FTE funded positions to do them – but keeping on our current pathway there will be little change. Frameworks, mapping, systems approaches and solutions are the tools we need to strategically advocate for change from our policy makers. We can’t discount or neglect the amazing work that is happening in the field, but if we don’t collect the evidence, and more importantly, hand that evidence to our politicians on a silver platter – they aren’t going to find it before they start talking, and more importantly, deciding about sex.
So, that leaves me at the end. To finish my PhD. To make an appointment with my local members about my framework. To be a little bit more annoying. Oh, and to enrol to attend ASHM. What are you going to do?
Listen to the Southside Grind podcast about Sexrurality here
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