Sexual and reproductive health and rights (SRHR) education with homeless people in Sweden

Abstract

This paper describes the implementation of an educational intervention to enhance sexual health among homeless people by including sexual and reproductive health and rights (SRHR) as a part of social work provision with this group. Adult service users in different forms of temporary accommodation were provided with the opportunity to participate in three group sessions. Seventeen sessions, six with women and eleven with men, took place at six different housing facilities in Gothenburg. The intervention implementation process (which involved preparation, creation, realisation and evaluation) is described, and factors of importance are identified. Service users appreciated the opportunity to receive information and discuss sexual health, rights and norms. The success of the work may be related to the fact that the project was anchored both in social services and among service users, constantly adjusted, and delivered using a respectful approach. Social work organisations and professionals have an important role to play in acknowledging and promoting service users’ sexual health and rights, especially among disadvantaged and socially excluded groups including homeless people.

Keywords:

• Homeless people
• sex education
• sexual health intervention
• sexual and reproductive health and rights (SRHR)
• social work

Introduction

This paper concerns the implementation of a sexual and reproductive health and rights (SRHR) education intervention for adult homeless people in different forms of temporary supportive housing in Sweden. It focusses on social work staff preparedness, and the importance of addressing SRHR in this field. Homelessness in Sweden is defined in terms of the following four situations (1) acute homelessness (e.g. living in shelter, protected residence, sleeping outdoors or in tents, cars etc.), (2) being in institutional or supportive care (e.g. in a correctional facility, group home or supportive housing), (3) being in a long-term housing solution (e.g. housing arranged by the municipality, often with some kind of supervision, rules and conditions), or (4) being in personally arranged housing (e.g. living temporarily without a housing contract with friends, family or others) (National Board of Health and Welfare 2017a). The paper mainly concerns people who find themselves in the first, second and third homelessness situations.

In Sweden, with nine million inhabitants, approximately 34,000 adults were reported as homeless in 2011: in the latest assessment from 2017 the estimated number was 33 250, a decrease said to be due to fewer municipalities taking part in the later survey (National Board of Health and Welfare 2017a, 2017b). At both measurement points the largest group were in long-term housing solutions provided by social services within the municipality, and in the 2017 survey 62% were men and one third were parents of a child under the age of 18. Approximately 24,000 children were reported to have a parent in either of the four situations of homelessness. In the most recent survey, 43% of homeless people were born outside Sweden, compared to 34% in the 2011 survey.

Homelessness is more than the lack of stable housing, it is also strongly connected to impaired health and increased mortality. Mental health problems and substance dependency are overrepresented among homeless people. In northern Europe, a Danish nationwide, ten year prospective, register-based study of 32,711 homeless people (30% women, 70% men) found that more than half, 58% of the women and 62% of the men, had recorded psychiatric diagnoses. A substance abuse diagnosis was found among 37% of the women and 49% of the men, and remaining life expectancy was substantially lower for both women and men, compared to the general Danish population (Nielsen et al. 2011). In a systematic review, childhood physical and sexual abuse was found to be more prevalent among homeless people in Western countries. The mean prevalence of childhood physical abuse was 37% (range from 6 to 94%). Reported childhood sexual abuse ranged from 4 to 62%, with average prevalence estimated as 32% for women and 10% for men (Sundin and Baguley 2015).

Regarding sexual health, homelessness has been described as a significant public health issue that increases the risk of HIV acquisition and transmission, and adversely affects the health of people living with HIV (Wolitski, Kidder, and Fenton 2007). In a North American study investigating sexually transmitted infections (STIs) and HIV risk, prevention behaviour and recent use of prevention and treatment services among people in homelessness in Los Angeles, 421 persons (30% women, 70% men) were interviewed (Wenzel et al. 2017). Thirty-seven percent had been sexually active during the previous three months; of these 75% reported unprotected sex, 30% reported multiple partners and 12% exchange sex. In the sexually active sub-sample, 73% reported HIV testing, and 48% testing for another STI. Ten percent reported being HIV- positive, and among them nine of ten were prescribed antiretroviral medication. In a different study with the goal of examining how social networks change during the transition from homelessness to permanent supportive housing, and in what ways the transition may affect HIV risk behaviour, 25 persons entering supportive housing in Los Angeles, responded to a questionnaire and interview. Findings suggest that HIV risk may increase once individuals are housed, either by introducing new risks or by intensifying existing HIV risk behaviours (Henwood et al. 2017). In summary, to be homeless and to enter supportive housing, may be connected to elevated risk for sexual ill health.

The promotion of sexual health involves much more than STI and HIV prevention, and sexual and reproductive health is one of the eleven public health target areas in Sweden (Public Health Agency of Sweden 2017a). Sexuality and reproduction are viewed as important determinants for health, and to have control over and decide freely on matters related to sexuality, including sexual and reproductive health, and be free of coercion, discrimination and violence, is a human right fundamental to people’s experience of health and well-being (ibid.). Such a statement by the Swedish authorities aligns well with concern more generally for SRHR (WHO 2015).

Different forms of supportive housing for homeless people are settings in which social work takes place. However, little is known about social workers’ perceptions, knowledge and values about sexuality. In an exploratory survey with 112 social workers in the UK, it was found that sexuality was not easily engaged by some social workers due to religious beliefs and/or lack of knowledge and training (Schaub, Willis, and West-Dunk 2017). This may lead to experiences of discrimination by service users or colleagues, and restrict the support offered by social workers. Lack of knowledge among social workers may be an issue also in the Swedish context. A recent national study suggested that students attending higher education in social work, nursing, medicine and law do not receive satisfactory SRHR education (Public Health Agency of Sweden 2017b). A culture of silence regarding sexuality has been described in social work with another vulnerable group, young women in secure state care in Sweden. Staff expressed that young women should ‘rest from’ sexuality while in care, and discussions of sexuality were often postponed by professionals, or referred to someone else, or some other time (Överlien 2004, 72). There is much to suggest therefore that training in and knowledge of SRHR, and of how to promote sexual health within social work is insufficient.

To raise knowledge among professionals working with homeless people, a three-day course on sexual health and HIV prevention (Project STINA) was conducted between 2012 and 2014 in the social services department of Gothenburg, the second largest city in Sweden. Post-course evaluation showed that staff felt more comfortable raising issues on sexuality after participating (Blomqvist 2014). A sustained effort to enhance sexual health among service users was however lacking, and in response to this, project Snacka Sex (in English: Talk Sex) was initiated in 2014. Based on the assumption that all people, regardless of the social situations, have the right to highest attainable sexual health, homeless people in supportive housing were offered sexual health information and the opportunity to talk about and reflect on sexual health, rights and norms in group sessions. Apart from focussing directly on homeless people and their different sexual health needs, the project acknowledged the importance of including SRHR in everyday social work practice.

Aim

The aim of this article is to describe and critically reflect upon the implementation of the Snacka Sex educational programme. A description of the intervention process (preparing, creating, realising and evaluating) will be provided together with some analysis of issues raised during this process.

Methods

Snacka Sex was framed as an educational intervention, i.e. as an opportunity for knowledge sharing and reflection on sexual health, rights and norms. Two project leaders, a social worker with a master’s degree in social work and human rights (EW) and a social worker with experience from providing sex education (E-M.E), led the educational components of the project throughout. Both had previous experience from working in supportive housing. The third author (ML) provided supervision on sexuality education among vulnerable groups.

Setting

Between October 2015 and May 2016, service users and staff in eight different supportive housing contexts (i.e. three emergency housing and five supported housing settings) in Gothenburg participated in the project. While the eight housing facilities differed, all served people who had been living on the street, evicted from the regular housing market, released from correctional care or in any other way needing shelter or housing. Staff were present around the clock in emergency housing and from morning to night, or more occasionally in supported housing. Emergency housing and some supported housing offer meals. Staff offer support to service users in their contacts with social services, the police, substance use teams and other health care facilities. The duration of the stay varies between hours or weeks to several months. Overall, the aim is multifaceted: to exit drug use, to optimise mental and physical health and social relations hips, and to arrange entry to a more permanent housing solution. For an overview of the different housing contexts included in the study, see Table 1.

Table 1. Overview of housing characteristics, intervention elements and data sources.

	Housing facility A	Housing facility B	Housing facility C	Housing facility D	Housing facility E	Housing facility F	Housing facility G	Housing facility H	Total
Housing characteristics	Emergency housing. Ongoing substance use accepted.	Emergency housing. Ongoing substance use accepted.	Emergency housing. Ongoing substance use accepted	Supported housing. Ongoing substance use not accepted	Supported housing. Ongoing substance use not accepted	Supported housing. Service users in opiate treatment programme.	Supported housing	Supported housing	–
Gender and Age	Women only > 21 years	All genders > 21 years	All genders > 21 years	Women only > 21 years	Men only > 25 years	All genders >21 years	All genders > 25 years	All genders > 25 years	–
Hours of staff meetings pre- intervention	2 (1 h with staff group, 1 h with designated contact person)	2 (1 h with staff group, 1 h with designated contact person)	2 (1 h with staff group, 1 h with designated contact person)	2 (1 h with staff group, 1 h with designated contact person)	2 (1 h with staff group, 1 h with designated contact person)	2 (1 h with staff group, 1 h with designated contact person)	1 h (with staff group)	1 h (with staff group)	14 h
No of staff answering the pre-survey	4	5	3	6	5	5	6	6	40 staff
Staff education	(project STINA, 2012–2014)	(project STINA, 2012–2014)	(project STINA, 2012–2014)	(project STINA, 2012–2014)	(project STINA, 2012–2014)	(project STINA, 2012–2014)	One day	One day	–
Hours of pre-visits at housing facilities to meet service users	4	8	4	2	3	5	–	–	26 h
No of service users in group sessions (no of service users staying at housing at time of intervention)	8 (18)	15 (56)	6 (25)	4 (14)	9 (20)	3 (10)	–	–	45 service users (out of 143)
No of group sessions	2 (with women)	3 (with women) 3 (with men)	1 (with men)	1 (with women)	4 (with men)	3 (with men)	–	–	17 sessions
No of service users answering the post-course survey	1 woman	3 women, 4 men	None	1 woman	7 men	2 men	–	–	18 service users

At two housing facilities that had not been part of the STINA project (Supported housing G and H), staff education on SRHR was identified as a priority. Staff at these two facilities therefore received a day of training led by a certified sexologist and social worker. Service users in these two housing settings were not included in the educational intervention. In all, 143 service users staying in six different housing settings included in the Snacka Sex study, of which 45 chose to participate. A total of 17 group sessions were held with service users in six different housing contexts (Emergency housing A, B and C, and Supported housing D, E and F): six group sessions with women, and eleven with men. Apart from the experiences of project leaders, data in this paper derives from staff (conversations and a survey prior to group sessions) and from service users (conversations prior to group sessions, field notes made during group sessions, and a written survey completed following group session participation).

Data and data analysis

In a preparatory phase of work, staff in the housing facilities provided both oral and written input to inform the intervention. Forty people answered a brief survey which included the following six open-ended questions: (1) What areas, pertaining to the target group, do you consider important to raise during the group sessions, (2) What possible risks do you find important to consider, (3) In what areas, regarding sexual health and rights, would you want increased knowledge, (4) What would you want this project to contribute to, regarding sexual health and rights in the target group, (5) In what way could this project facilitate your work, and (6) Do you today require more knowledge/support, regarding working with service users’ sexual health? A narrative summary of staff input was prepared.

During the preparatory phase input was also sought from service users during extended visits to each housing context. This provided an opportunity to plan the later sessions in line with the values of service user inclusion (International Federation of Social Workers 2014). Very little input was however gained from service users during these visits. Rather, they served as a way of creating contact between service users and the project leaders, and to create interest in the event.

Another date source comprised the field notes taken by one of the project leaders (E-M.E) during group sessions with service users. These were later content analysed by E.W and M.L (Granheim and Lundman 2004; Krippendorff 2004). Meaning units (constellations of words or statements that related to the same central meaning) were identified, condensed, arranged and then rearranged. Three subthemes were constructed, and agreed upon by all three authors, describing what was discussed during the SRHR group sessions.

Following the group sessions, participants were asked to complete a brief survey which included five open-ended questions: (1) What was good during the group sessions, (2) What was not good during the group sessions, (3) Did you learn something, if so, what, (4) How did you feel about talking of these issues in a group, and (5) Was there some topic in particular that you missed? A space was then provided for any other comments. In one housing context it was not possible to complete this element of evaluation due to a violent situation. This excluded 14 service users. In all, 18 of the remaining 31 participants from five different housings filled out the survey in private: five women and thirteen men aged 25 to 57. A narrative summary of their answers was prepared.

Ethical considerations

Under Swedish research governance arrangements, because Snacka Sex was a development project in the Gothenburg social department, approval by an ethics review board was not needed or sought. However, once it became clear that the results could be of interest to a larger audience, oral consent to publish what was said during and after the group sessions was sought and obtained from all participating service users. No audio recording took place during the group sessions as this could have jeopardised the participants trust in the project and its leaders. For the same reason, no personal data apart from age and gender was collected from service users in the post-survey. Hence, the quotations used in this paper are not the verbatim accounts provided by participants but were created from field notes taken by one of the project leaders during and directly after the group sessions. This process was known about and orally approved of by all participants. All participants in the group sessions were adults, no personally identifying details are provided in this paper and experiences are presented at an aggregate level. This also applies to the oral and written input from staff.

Findings

Snacka Sex preparatory phase

Involving housing facility staff

Following preparatory meetings with staff at the eight supportive housing facilities, the oral and written input gathered was used to guide development of the group sessions. Feedback suggested that service users should be carefully prepared for the sessions, both in writing and orally. Staff suggested that the language used should be kept accessible to all, and that flexibility to attend all or some of the meetings should be allowed, as a way of respecting concentration difficulties among some service users. In all, staff were positive towards the upcoming group sessions, but also expressed some anxiety. They feared that the group sessions might be like opening a Pandora’s Box, that service users would share and reflect on traumatic experiences, and that this would be harmful and cause further psychological distress, in addition to the distress experienced in relation to other problems.

Involving service users

During the preparatory phase, project leaders spent time at six of the housing facilities at times of the day when service users were present to provide information to, and to gain input from service users. In the common room area of each facility, upcoming group sessions were advertised with posters. Boxes where service users could post notes with suggestions or questions were also installed. Very few notes were posted, however, and few suggestions received. However, the information giving and the installation of the boxes caused curiosity, and became a subject of conversation between service users and project leaders about the upcoming event.

Group session content and delivery

Apart from the information gathered from service users and staff, insight from research and from other professionals working with the target group (e.g. substance use teams, substitution treatment teams and sexual health teams) informed intervention development.

Similar projects were however hard to find, and existing education materials tended to have been developed for use with young people. Therefore, new material had to be developed. The following three themes helped structure the course: (1) body and anatomy (e.g. the clitoris, lubrication, penile erection), (2) sexuality, consent, drugs and safer sex and (e.g. the broad concept of sexuality and SRHR, the importance of consent, pros and cons of sex and drugs, STI/HVI prevention, the penile-vaginal intercourse norm), and (3) relations and relationships (e.g. how to flirt, how to maintain or end a relationship, norms of femininity and masculinity).

Because some service users had reading and writing difficulties, predominantly visual material was created, including pictures and short films, one for each theme. This visual material formed a smorgasbord that the specific group of participants could choose from. Project leaders were flexible to service users’ needs and wishes and hence each group session differed from others. A plastic vulva and a plastic penis were used as pedagogical aids in conversations about anatomy. Each group session was planned to focus on one of the three themes and lasted one hour, including breaks.

A gift pack was prepared for each participant. This contained information from organisations such as RFSU (a national NGO working with sexual health education and promotion), Kvinnofridslinjen (a national telephone support line for women exposed to threats or violence), Preventell (a national telephone support line aimed at persons who feel they have lost control over their sexuality, and fear hurting themselves or others), Mikamottagningen (a local counselling service for people with present or past experiences of selling sex), Kast (a local counselling service for people who buy sex or feel that they have lost control over their sexuality), and the Stödcentrum för brottsutsatta (a local counselling service offering advice and support to victims of crime). The gift pack contained information about HIV and hepatitis, hepatitis vaccination cards and local sexual health services. It also contained shower cream, body lotion, lubricants, condoms and some sweets. The purpose of the bag was to create an interest in the event, and to provide information that the service user could use later in their own time.

Snacka Sex development and implementation

In line with service users’ wishes, separate sessions were organised for women and for men, but participants were encouraged to join the group best matching their gender identity, in an effort to include transgender and non-binary gendered people. Each session lasted longer than planned, on average one and a half to two hours. The need to allow for discussion during the sessions’ closing was identified, and in one location (Supported housing E) a fourth session was held with one group.

At some housing facilities, all three sessions were held during the same week due to participants’ status (i.e. active drug use) and to optimise the possibility of reaching them. It was decided, again in consultation with service users, that housing staff should not be present. However, all participants agreed that staff could be told afterwards, in general terms, what had been discussed. In cooperation with housing facility staff, service users in a psychotic state or severely affected by drugs were not invited to participate. This only happened on two occasions.

Each session began with the setting of ground rules (e.g. showing respect for others and their opinions, how to avoid being too private, not disclosing others), and information about the fact that project leaders being available after the session should someone want to talk to them in private.

Issues discussed

Three subthemes identify what participants focused on during the SRHR sessions. For the purpose of this presentation, participants quoted have been given a pseudonym, and an approximate age.

Vulnerability and insecurity

Many, both women and men described experiences of sexual assault as children. For many, this was a secret that had been hidden for a long time, often due to feelings of shame.

I usually don’t tell people that I was sexually assaulted as a child. Quite often you hear that people who have been assaulted turn into assaulters. So, I have been afraid that people might see me as a paedophile if I tell them. (Alan, late forties)

Some described using drugs to self-medicate and ease feelings of shame. Many described not being listened to, or believed, when they had told someone else about their experiences of assault. Sometimes, difficult living conditions had hindered them from seeking counselling while adding to the risk for further sexual exposure. If a person needed money for drugs or somewhere to sleep it could be difficult to protect oneself or to choose when and with whom to have sex. Many women described difficulties negotiating condom use, especially during transactional sex:

I have never done it, and don’t judge anyone for doing it, but you can see that they are not feeling good. Sometimes they bring the men here, to the housing. Sometimes they stand just outside here. A friend of mine told me she’d sold to a really old man. She felt repulsed. (Meg, mid-forties)

Although both women and men described negative sexual experiences, women appeared to be more exposed. Almost all the women had experienced different forms of sexual abuse and many said that they had rarely had the possibility to discuss this with family, friends or professionals. In addition, sexual health, rights and norms were subjects they had rarely talked about:

I have lived in many group homes, and I have been in groups like this before, but never talked about these things. (Angela, mid-thirties)

Men talked about relationships and norms of masculinity during group sessions. Many expressed difficulty adhering to the image of a strong, active, economically independent and sexually potent man when they lacked both a home and libido. They spoke about how relationships were hard to maintain when using drugs, and of problems finding a drug-free partner. Likewise, women expressed difficulty adhering to norms of femininity, especially being a sexually active and available woman. Many women found sex difficult due to previous negative experiences and told stories of sexual violence and relationship break up:

He has said sorry so many times and promised that it will never happen again. He comes for me wherever I stay. He finds me even though I have told no one where I am. (Emma, mid-fifties)

The link between sex and drugs

Sometimes the onset of drug use was described as linked to sexuality: as relief from anxiety due to previous sexual abuse, or as a means of overcoming sexual inhibitions, daring to flirt or hook up. Many participants described never having had sex when not under the influence of drugs, and of how drug use affected sexual consent and practice, hindering the ability to know what a partner wanted:

We were both high back then. We used to wake each other in the middle of the night and have sex. But, now that I think back, I’m not sure she was into it at all times. (Tom, mid-forties)

Many women had experiences of their male partner being less sensitive due to drug use, and that when the partner was high they lacked awareness of to anything other than their own needs. It was said that drugs and psychotropic medication affected both the wish to, and the ability to have, sex. Some participants said they were so used to having sex on amphetamine that did not know if they could, or would want to, have sex without this. Others discussed how opiate use and opiate substitution medication affected libido and the ability to have sex, often leading to the use of other drugs:

I started with amphetamine, when I was on Subutex, to get back the wish to fuck, because I got no help from the health care. So, I started lying and cheating with the urine samples. I got thrown out of the programme because of this. (Michael, early forties)

The connection between drug use and sex was also described as causing problems for those wanting to leave drug use, partly because sex was experienced as more rewarding when on drugs and partly because it was hard to find a new (drug-free) partner:

Me and my friend, we talked after that NA-meeting. We reached the conclusion that no normal person will ever want us. Who would want a guy attending NA-meetings? So, we went and had a relapse together. (Tom, mid-forties)

Relational difficulties within a system

Drug use and overall life situation affected relationships negatively. A safe and satisfactory sex life was hard to achieve while being part of a system in supportive housing or a treatment facility where rules and regulations hindered sexual relations with others:

We have been together for ages. She has been in different treatment facilities, but wanted to be with me, to sleep with me, and she broke the rules, and was thrown out. Lived with me in the car, started to use drugs again. (Michael, early forties)

Many said that if sexuality was ever discussed with professionals, it was often viewed in a problematic or negative way by professionals. This one-sidedness was objected to by participants. Although they described experiences of sexual abuse, positive experiences also existed and participants wanted these to be acknowledged by professionals:

I find it difficult to have a relationship when being homeless, because sexuality is never discussed, and if it is, it is only the bad stuff, ‘Don’t you feel abused?’ and so on. They never focus on the good stuff. (Sally, late twenties)

Evaluation of Snacka Sex

Participant experiences

Positive and negative experience of group sessions

In answers to the survey of experience of the group sessions, participants mentioned information on safer sex and anatomy as something positive. The chance to talking about drugs and sexuality was also mentioned as constructive. Many described the atmosphere during group sessions as open and supportive. Some described how they appreciated the fact that something happened at their housing facility. Very few mentioned negative experiences, the ones who did wrote about other participants’ behaviour (e.g. not showing up on time, interruptings).

Knowledge gained from group sessions

Most participants said they appreciated discussing safer sex and anatomy and some said they had shared this new knowledge with others through discussion. Knowledge gains in other areas was also mentioned, for instance that it is possible to make anonymous calls to support lines and the fact that men can experience sexual assault. Some described gaining knowledge on the concept of shame, and those with experiences of sexual assault wrote that they had learned something important about themselves, and about their self-esteem and reactions.

Talking about sex in group sessions

The majority of participants stated that they appreciated the group sessions. Half said that they had been a bit nerve-wracking, but at the same time they were fun, and it was interesting to talk about sex in a group and learn from the experiences and reflections of others. Several wrote they had rarely or never discussed sexual health with others.

Themes lacking in the group sessions

Most respondents said that they would have appreciated more specific advice on sexual relations, on how to meet a partner, on how to make a relation work and what to do when a relation does not work, or when it becomes violent. Some stated that they would like to receive individual counselling, and others said that they would have liked more information on sexuality and disability, and on sexuality and chronic diseases.

Success in the intervention process

Three areas were identified by ourselves as key to the success of the implementation process: anchoring (in the organisation and among service users), adjusting (to needs and wishes of service users), and approach (having a respectful and sex positive approach):

Anchoring

The project was viewed as important at different levels of the organisation (i.e. by the head of the social work department, by the head of each supportive housing facility and by most staff within it). One effect of this anchoring could be seen in service user attendance. In housing facilities where a greater interest was shown by staff, service users appeared more interested and attended the sessions more regularly. That the project leaders were anchored in the field of sexual health, in social work and human rights, and in adopting a norm critical perspective was also deemed as important. The preparatory visits to different housing facilities, meeting service users and staff before the sessions, were also of significance.

Adjustment

Gender distinct groups can be both heteronormative and excluding of transgender people, but participants appreciated this. Women especially said that in gender divided groups they felt safe. Appropriate language and a visual approach (having more pictures than words in the presentations used) were also seen as valuable. Not allowing staff at the housing facility to be present was another adjustment to service users’ wishes. This may on the one hand have signalled that sexuality and sexual health were topics that can not be discussed with staff. On the other hand, experiences of homelessness could entail a mistrust in authorities, and having staff present could have felt like having a social worker listening in on a private matter. Project leaders’ outsider status was deemed of benefit to the project and to the open conversations that were held.

Approach

An awareness of the potentially artificial situation when two relatively young women entered the temporary homes of adults, often their seniors, to teach about sex, was present and constantly acknowledged throughout the project. To counteract this, the existing knowledge of service users was sought and affirmed. Hence the sessions took the form of respectful conversations between adults, focusing not only on negative experiences but also on resilience, positive experiences and the future. Being homeless includes being left out of the decisions of others and subject to authorities and their rules and regulations. Service users described experiences of being treated with disrespect, both by authorities and professionals, in matters concerning sexuality. Therefore, recognising service users as sexually competent and the holders of sexual rights was critical. The project leaders tried to be non-judgemental and to focus not only on negative but also on positive experiences. Transactional sex was also discussed matter-of-factly, and regarded as a rational strategy to adopt in a difficult life situation.

Discussion

When an intervention is carried out, it is of value to discuss what worked, why, and for whom (Pawson and Tilley 1997). In this study, anchoring, adjustment and approach were identified as being of major importance and may explain the overall positive response from participants. However, the study has several limitations that may affect overall trustworthiness and the conclusions that can be reached. For instance, a more structured theory-based evaluation could have been conducted. Moreover, it is not possible to evaluate if taking part in the group sessions strengthened participants’ sexual health or not. Crucially, the intervention was educational in nature and took into account the needs and wishes of participants. Ongoing adjustment throughout implementation was identified as one of its successful components but also hindered the application of a more rigorous and structured form of evaluation.

Vulnerable or hard to reach groups have been described as less inclined to participate in sexuality research (Wellings and Collumbien 2012). That almost one third of the service users in the different supportive housing facilities chose to participate can therefore be seen as successful, given their overall life situation, health circumstances and on-going substance use among some members of the group. Another limitation derived from the fact that service users were not given the option to evaluate their experiences orally, taking reading and writing difficulties into account. This option might have increased the number of participants responding to the post-event survey. Nothing is known of service users who chose not to participate in the group-sessions, and some may have been even more vulnerable than the ones participating.

Our decision not to collect personal information from service users could affect the study’s trustworthiness. In making this decision the ethical aspects outweighed other considerations. It is our view that asking for detailed sociodemographic data would likely have made service users less inclined to participate. Mentioning this raises the question of our dual roles as both implementers and researchers. Although initially framed as a local developmental project, the project can also be understood as action research orientated towards change (improved sexual health), involving participants, and with researchers actively involved in the situation or phenomenon being studied (Robson 2002). This dual role may be advantageous when introducing and evaluating new services in a complex field; the researcher gains deeper insight to the situation and phenomena being studied (Trondsen and Sandaunet 2009). On the other hand, when an evaluator contributes to the process of change and is then supposed to verify the changes made, the need for a ‘double mind’ is evident (Olsen and Lindøe 2004.). In an effort to be transparent, a ‘super audit trail’ as described by Rolfe (2006, 309) is provided throughout this paper, explaining both the rationale underpinning the project and the decisions made en route, as well as the actual rather than idealised course of events during the project.

The project was funded by the Public Health Agency of Sweden and carried out within the municipality of Gothenburg. As funding ended, due to a major decrease in government ‘HIV-funding’, work came to a close. In other words, no stakeholders remain today, and users neither had nor have any ongoing influence over access to future SRHR group sessions. As evaluators we had different roles. The first and second author were active in the actual implementation, the third author was more passive in implementation, while being active in evaluation.

Finally, since norms on sexuality are shaped by the cultural context, the findings may not be easily transferrable to any other setting. However, the processes described may serve as an inspiration to others working in similar settings who desire to include SRHR in their social work practice with homeless people.

Conclusion

The aim of the Snacka Sex project, to offer adult homeless people knowledge and the opportunity to discuss sexual health, rights and norms in a safe and health promoting setting was reached. Findings show that sexuality and substance use are intimately connected among members of this vulnerable group, and that sexual relationships can be hard to maitain when using drugs and being within the social work system. Moreover, staff in two housing facilities received knowledge preparing them for possible future work on SRHR.

One of the most discussed areas during group sessions with service users concerned how sexual relations can be affected by substance use, and the difficulties of adjusting to societal norms on sexuality and gender. Although participants were adults, their comments echo what young people (both in national samples and samples of vulnerable young people in state care) in Sweden say when asked what has been lacking in sexuality education (Public Health Agency of Sweden 2017c, forthcoming). This underlines how the relational aspects of sexuality remain crucial throughout the lifecourse and how sex education may be appreciated also by adults.

Participants reported that they rarely or ever had talked to someone else about sexual health, rights and norms, which mirrors the culture of silence concerning sexuality described in previous work with vulnerable groups (Överlien 2004). Findings suggest that this silence cannot be attributed to service users alone. Participants explained that to be uncertain and worried about sex when drug-free can affect the motivation to stay clean. This finding is line with previous research on substance use and sexuality. It is both important and challenging for people exiting substance use, to have, or to reclaim, their sexuality and to have new sexual experiences in the absence of alcohol or other drugs (Skårner, Månsson, and Svensson 2016; Svensson and Skårner 2014).

Experiences of sexual abuse and of abusing others were also shared by participants, together with the feelings of shame connected to this. Physical violence and substance abuse are topics often discussed with others, but not sexual abuse. In group sessions, the possibility of doing so in an undramatic and non-judgemental fashion were much appreciated by the participants. Overall, our findings underline the importance of including discussion of sexual trauma in social work practice. But, as participants stressed, professionals need to focus not only on the negative sexual experiences, but also on the positive ones, and acknowledge that these experiences exist simultaneously.

None of the participants expressed, either orally or in writing, that taking part in the group sessions aroused feelings they were not already used to or which decreased their psychological well-being. On the contrary, many service users approached the project leaders, after and in between group meetings, for counselling or discussion. Service users’ experiences of taking part in group sessions can therefore be understood as an example of how dialogue on sexuality can be experienced as having the right to your body, integrity and desire respected. To be acknowledged as a sexual being can affirm you as a person, an important aspect in all human interaction, not least in social work with vulnerable people. The Pandora’s Box feared by staff at the housing facilities did not occur. Rather, the box appears to have needed opening.

Funding

This work was supported by the Public Health Agency of Sweden. The funding agency had no influence over the process or conclusions reached. The views expressed are those of the authors alone and are not necessarily those of the funder.

Disclosure statement

No potential conflict of interest was reported by the authors.

Acknowledgements

We thank the service users and staff, especially Kajsa Björnestedt at City of Gothenburg, involved with the Snacka Sex project. We also thank Suzann Larsdotter and Ronny Tikkanen for their input to this paper.