COVID-19 and access to sexual and reproductive healthcare for young people

ABSTRACT

[...]the incidence of COVID-19 is lower in children than adults,1 and the prevalence of severe disease is lower among children than adults.2-4 Furthermore, medium-term sequelae (four months) have proven rare among children who recover from COVID-19,5 and their case fatality rate is also lower than that of adults.4 The World Health Organization (WHO) defines adolescents as individuals aged between 10 and 19 years;however, research often focuses on young people, defined as people under the age of 25 years.6 SRH covers services that promote sexual wellbeing and reproductive health, and prevent and treat sexually transmissible infections (STIs) and blood-borne viruses (BBVs). Adolescence and young adulthood are risky times for the development of mental health problems, with most disorders commencing during this time;however, diagnosis may occur later if healthcare access is limited.12 Young people are often reluctant to seek help, particularly if services are not specifically designed for young people.13 Young people with poor mental health have higher rates of physical health problems, including those related to SRH.12 This makes access to appropriate, high-quality mental healthcare for young people critical for maintaining their SRH. Results Sexual and reproductive wellbeing of young people during the COVID-19 pandemic In an Australian survey during lockdown (66.3% respondents aged 18-29 years), the frequency of sex with a partner varied depending on cohabitation, with the survey suggesting fewer casual partners and less group sex, while use of sex toys and masturbation increased.15 Some women also reported delaying childbearing because of the pandemic.16 Surveys from China reported reduced frequency of sex,17 reduced number of partners,17 increased relationship dissatisfaction18 and increased use of pornography.18 This is likely due to lockdown conditions and the high number of young people who live with their parents.17'18 A US survey of sexual minority males aged 14-17 years mirrored this finding, with online sexting and messaging becoming more common.19 This contrasted with data from African nations, where pockets of increased sexual activity20 led to increases in teenage pregnancy.21 School closures have been implicated with less visibility of children and increased potential for abuse from family and neighbours.21 One article highlighted the potential longer-term reduction in sexual wellbeing, with young people having reduced 'normative experiences' due to lockdown and increased parental scrutiny.22 The authors suggested increasing focus on young people in post-lockdown periods to ensure their sexual wellbeing.22 Access to sexual and reproductive healthcare during COVID-19 In Australia and internationally, SRH - including access to contraception and abortion services, STI screening and treatment, and HIV care - is recognised as an essential service during the COVID-19 pandemic.23-25 Despite this recognition, a rapid survey of 64 nations found services were scaled back across all nations and 5633 SRH clinics closed;26 2 7 00 young people from Africa reported reductions in access to SRH services due to clinic closures and fear of contracting COVID-19.20 As a result, contraception, HIV care, abortion services and comprehensive sexuality education (including menstrual education)20 for youth have been affected.26 A semi-rural area in the UK saw no people aged under 18 years access emergency contraception for six weeks, and there was a fall in accessing other sexual health services, especially for those aged under 18 years.27 This may be appropriate (eg a result of reduced intimacy18'22'27) or inappropriate (eg a consequence of disruption to public transport).28 The review also highlighted that young people may feel judged if they have broken lockdown restrictions and then need SRH.27 Few articles were focused on SRH within a generalist setting, such as general practice, so issues such as opportunistic preventive healthcare, cervical screening and general healthcare were not discussed. In the setting of SRH, telehealth can be used for contraception,10'25'29-33 STI screening,27'34 syndromic management of STIs28'33 and medical abortion.17'23'24'27'30'32'35 However, challenges to providing SRH via telehealth included * maintaining confidentiality and privacy;especially for young people in crowded housing during lockdown conditions22,27 * providing culturally appropriate care22 * examining sensitive body parts33 * institutional support to implement telehealth, including appropriate funding and access to technology.33 Telehealth is also more difficult for those without access to a device and for individuals with poor internet access.22'31'33 Suggestions for overcoming these barriers are outlined in Table 1.