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Syndemic service integration: Are sexual health clinics appropriate settings for addressing clients’ unmet mental health care needs?


Sexually transmitted and blood-borne infections (STBBI), and mental health and substance misuse problems co-occur at elevated rates in particular socially-marginalized sub-populations (e.g., sexual and gender minorities). This is primarily due to socio-structural processes of discrimination, exclusion, and segregation. These overlapping epidemics, or ‘syndemics’, are exacerbated by challenges these same sub-populations face in accessing culturally-safe and sexual/gender minority-affirming mental health services. In this context, STBBI (or sexual health) clinics may offer unique opportunities to respond to unmet mental health care needs—particularly for members of marginalized groups.

Publicly-funded sexual health clinics have three features that render them potentially opportune sites for addressing inequities in mental health care access:

  1. They do not require a referral from a primary care provider, making them accessible to those without a family doctor.
  2. They are free of cost to the user and do not require health insurance.
  3. In many cases, their staff are trained in the provision of sexuality-affirming and anti-stigmatizing care.

Summary of research

We conducted a waiting room survey at six urban and suburban STBBI clinics in Metro Vancouver, between November 2016 and July 2017.  Our research goal was to characterize clients’ needs, barriers, and interest in mental health services.

A total of 1,115 clients responded to the survey; 65% were sexual minorities (lesbian, bisexual, gay, pansexual, or queer), and 2% were gender minorities (transgender or gender non-binary).

Mental health needs

Overall, 39% of clients reported a current need for mental health support, particularly with respect to:

  • Anxiety (29%)
  • Depression (26%)
  • Substance use (10%)
  • Suicide ideation (7%)

Among clients with a current mental health care need, 72% of had not yet talked to a health care provider about their concern.


The most commonly reported barriers to accessing mental health care were embarrassment or shame about their mental health (26%), cost of services (24%), or lack of extended health insurance (18%).

Sexual and gender minorities were more likely than cisgender heterosexual respondents to report a barrier to accessing mental health services, as were clients attending clinics in suburban settings.


When asked about who they could talk to about their mental health, 88% of clients indicated they were comfortable discussing mental health concerns with an STBBI clinic nurse or physician. By comparison, 70% were comfortable talking to a family doctor, though 42% of clients did not have a regular doctor.

Eighty-five percent of survey respondents expressed interest in receiving mental health assessments, referrals, or short-term counseling at the STBBI clinic.

Implications for practice

This study provided a statistical profile of the opportunity for publicly-funded sexual health clinics to assess and refer clients affected by syndemic-related drivers of STBBI to mental health services. We found a large burden of unmet mental health care needs, most frequently related to anxiety, depression, substance use, or suicide. Encouragingly, we also found a high degree of comfort and interest in receiving mental health services at the STI clinic.

In 2018, we will be conducting interviews with STBBI clinic providers and administrators throughout the province. These interviews will build on the survey results to understand current STBBI clinic practices with regard to mental health, and to identify and recommend future interventions.

For further information

If you would like to receive more details about this study, or would like to participate in an interview, please contact Travis Salway at the BC Centre for Disease Control: travis.salway@bccdc.ca.


This study was made possible through the generous and hard work of staff and volunteers at the Health Initiative for Men and the BC Centre for Disease Control. Thank you, especially, to Aaron Purdie at HIM and Troy Grennan, Dean Mirau, and Natalie Holgerson at BCCDC.

Thank you also to our study collaborators: Olivier Ferlatte, Teddy Consolacion, Naomi Dove, Ashleigh Rich, Kai Scott, Everett Blackwell, Hasina Samji, Jeannie Shoveller, and Mark Gilbert.