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Sexual wellbeing is considered a key aspect of sexual health, which the World Health Organization defines as a “state of physical, emotional, mental and social wellbeing in relation to sexuality”. In essence, sexual wellbeing encompasses sexual health, pleasure, quality of life, and justice — ensuring that sexual experiences are free from discrimination, violence, and coercion.

Sexual wellbeing therefore reflects a safe, respectful, and satisfying sex life. It can be compromised by factors such as unintended pregnancy, psychological harm, sexual violence, and sexually transmitted infections (STIs). Community pharmacies play an important role in addressing these risks and supporting sexual wellbeing.

Policy perspective on sexual wellbeing

The first oral contraceptive was launched in the UK in 1961 and became available on prescription. Even so, it wasn’t until 1967 that the Government considered the importance of sexual wellbeing, following the introduction of the Family Planning Act.

The Act enabled local health authorities to offer birth control advice and contraception, irrespective of marital status, via the Family Planning Association. In the same year, a further important development for sexual wellbeing was the Abortion Act 1967. While the Act did not decriminalise abortion, it would now be permitted under specific circumstances.

By the 1970s, family planning services had been incorporated into the NHS. However, a major turning point in the Government’s response to sexual health occurred during the early 1980s because of the HIV/AIDS epidemic. Despite this, it took until 2001 for the Government in England to introduce its first national strategy on sexual health – Better Prevention, Better Services, Better Sexual Health. Its key aim was to ensure better access to sexual health information and dedicated services.

It wasn’t until the Health and Social Care Act 2012 that commissioning arrangements for sexual, reproductive health, and HIV were devolved to a local level. This led to the 2013 report, A Framework for Sexual Health Improvement in England, which sought to:

• Improve sexual health and wellbeing across the population
• Reduce inequalities
• Create a culture in which everyone could make informed choices about relationships and sex.

Unfortunately, as with most NHS services, funding became a major issue. In 2018, a crisis in sexual health service funding prompted a joint letter from the Royal College of General Practitioners, the Royal College of Obstetricians and Gynaecologists, and the Faculty of Sexual and Reproductive Healthcare. It outlined how funding cuts had fragmented service provision, exacerbating health inequalities.

By 2022, the Local Government Association report, Breaking Point: Securing the Future of Sexual Health Services, highlighted that lack of funding could reverse the previous reductions in STIs and unwanted pregnancies.

Traditionally, sexual health services had been provided by genitourinary medicine or sexual and reproductive health clinics, but increased demand forced local commissioners to explore additional service providers. One untapped resource was community pharmacy.

Evolving pharmacy’s role in sexual health services

The idea that community pharmacy has a role to play in sexual health services is not new. Although mentioned in the 2008 White Paper, Pharmacy in England: Building on Strengths – Delivering the Future, pharmacies had already begun playing a role as early as 1999, when emergency hormonal contraception (EHC) became available.

By 2001, EHC was deregulated as a Pharmacy-only medicine, and by 2005 the provision of EHC was included as an enhanced service in England’s pharmacy contractual framework. Following successful pilot schemes, pharmacies could also provide screening for STIs such as chlamydia, especially opportunistic screening when providing EHC.

In 2019, a briefing document for commissioners, The Pharmacy Offer for Sexual Health, Reproductive Health and HIV: A Resource for Commissioners and Providers, raised awareness of the potential role of community pharmacy in sexual health services.

A 2021 review identified the main components of community pharmacy-based sexual health services as:

• Screening for STIs and blood-borne infections (e.g. HIV, HPV, hepatitis C)
• Prescribing contraception
• Erectile dysfunction management
• Pregnancy and preconception care

In recognition of how community pharmacy teams can support sexual wellbeing, an advanced contraceptive service was launched in English pharmacies in 2023, although groundwork had begun nearly 20 years earlier.

Lambeth study: a pivotal moment

Studies in the early 2000s highlighted that community pharmacy could play an important role in supporting sexual wellbeing. As EHC provision became commonplace, it seemed natural that pharmacy’s role could extend to include the supply of oral contraceptives.

This was first explored in a 2008 pilot study in Southwark and Lambeth, which examined the initiation and continued supply of 14 oral contraceptives via a Patient Group Direction (PGD).

Key findings included:

• 32% of consultations led to the initiation of an oral contraceptive
• High levels of client satisfaction
• A significant drop in EHC requests following the service introduction.

Despite this innovation, it took the NHS until 2021 to pilot the service on a wider scale.

Pharmacy Contraception Service

The service was separated into four tiers. In the first tier, pharmacists were able to supply women with repeat prescriptions for ongoing supply of an oral contraceptive. By 2022, pharmacists could move to the second tier and initiate oral contraceptive use themselves. The position in Scottish pharmacies was, however, slightly different. 

The Bridge-It trial, published in 2020, had demonstrated that the provision of a bridging (three-month) supply of the progestogen-only pill to women requesting EHC resulted in a significantly higher proportion using an effective method of contraception four months later compared to EHC supply alone.

Consequently, since 2021, pharmacists in Scotland have been permitted to make a three-month supply of desogestrel 75mg either following a request for EHC or as an initial treatment. A similar service has been operational in Welsh pharmacies since 2022. 

The English Pharmacy Contraception Service (PCS) now enables both EHC and the initiation and continued supply of an oral contraceptive. In a further development, the service can also be provided by registered pharmacy technicians. 

Supplying oral contraception

The PCS allows one of the following, either for initiation or ongoing supply:

• Combined oral contraceptive (products listed in the PGD) for women from menarche up to 49 years
• Progestogen-only pill (norethisterone, levonorgestrel, desogestrel) from menarche up to 54 years
• Drospirenone-only from menarche up to 49 years.

Supply can continue for a minimum of six months and a maximum of 12 months, provided inclusion and exclusion criteria are met.

Emergency contraception (EHC)

The PCS allows for free supply of EHC (ulipristal acetate 30mg). Previously available OTC or via local services, incorporating EHC into a national service helps reduce inequalities.

EHC can be provided to women:

• Between 0 and 120 hours following unprotected sex
• When regular contraception has failed or been used incorrectly
• If vomiting occurs within three hours of taking EHC
• Full PGD inclusion and exclusion criteria apply.

Providing services to under-16s

Supplying contraceptives to girls under 16 years of age requires vigilance. Two key terms for pharmacists:

• Gillick competence: Determines a child’s capacity to consent to any treatment
• Fraser guidelines: Specifically relate to consent for contraceptive or sexual health advice.

Key points:

• Pharmacists must ensure the child fully understands the advice and cannot be persuaded to involve parents
• Assess whether the child would continue sexual activity with or without contraception
• Children under 13 should rarely be treated without parental involvement; sexual activity under 13 is a criminal offence and requires a child protection referral

Conclusion

The extension of the PCS in England to include oral contraception and EHC is a positive development. Pharmacies have demonstrated the feasibility of screening and treatment services for STIs, showing the sector has much to offer.

With traditional sexual health services increasingly stretched, community pharmacists are well placed to support sexual wellbeing, particularly in reaching hard-to-reach groups. National consolidation of these services is now timely and necessary.