Abstract
Keywords
Dear Editor-in-Chief,
I am interested in the findings of this study because Ogaz et al. 1 show that the issue of access to sexual health services is not only related to the availability of facilities, but also to how service systems determine who is more easily reached and who remains left behind. Among 2404 male and gender-diverse participants who have sex with men in England, 86% had accessed face-to-face sexual health services, yet 12% of those who tried to access services in the previous year still experienced unmet needs. The most prominent barriers were the unavailability of appointments and service hours that did not suit users’ needs, with greater inequality outside London than in London.
For readers less familiar with Foucault’s work, his theoretical lens is useful because it explains how modern institutions govern populations not only through law or prohibition, but also through knowledge, surveillance, categorisation, and prevention. 2 Foucault’s 2 concept of biopolitics refers to the ways in which states and institutions manage life at the population level by collecting information, identifying risks, shaping behaviour, and organising access to care. In sexual health, this can be seen in practices such as STI screening, PrEP eligibility assessment, vaccination programmes, digital triage, partner notification, surveillance data, and the classification of individuals into different levels of sexual risk.
These findings are important to read through Foucault 2 because sexual health services function not only as spaces of healing, but also as spaces in which bodies, risks, behaviours, and sexual identities are regulated. Within a biopolitical framework, the modern state no longer governs citizens merely through prohibition, but through mechanisms for managing life, such as STI screening, PrEP, vaccination, digital triage, partner notification, and the classification of risk groups. Foucault 2 shows that sexuality becomes an object of knowledge and social administration, meaning that the sexual body is never truly neutral, as it is always interpreted through categories such as normal, at risk, compliant, healthy, or deviant.
This philosophical perspective is also relevant to current debates in sexual health service delivery, particularly the screening of asymptomatic people. 3 Asymptomatic STI screening is often presented as a neutral and preventive public health intervention, but it also depends on systems that decide who should be invited, prioritised, tested, deferred, or reassured. In this sense, screening does not merely detect infection; it also produces categories of risk and responsibility. 4 A Foucauldian analysis helps show that people who do not appear visibly ill may still be governed through anticipatory forms of surveillance, while human rights analysis reminds us that preventive services must remain accessible, non-stigmatising, and responsive to diverse needs. This is especially important because people without symptoms may be less likely to perceive themselves as eligible or urgent, even though early testing can support both individual health and wider public health goals.
When this study finds that those with markers of sexual risk were less likely to experience unmet need, this can be read as a success of the system in prioritising clinical risk, but also as evidence that access is often granted through a logic of biopolitical selection, namely who is considered most in need, most urgent, and most compatible with the design of the service. The problem is that the right to health must not depend solely on whether a person fits into a risk category that is easily recognised by the system. The right to health under Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) requires access to health services that are available, accessible, acceptable, and of good quality without discrimination.5,6 In addition, General Comment No. 22 affirms that sexual and reproductive health is part of the right to health, meaning that the state has an obligation to remove structural barriers, including geographical, economic, disability-related, stigma-related, and digital barriers.7,8
In this context, the fact that participants with long-term physical conditions that limit daily activities had a higher likelihood of experiencing unmet service needs shows that a system that appears open is not necessarily truly equitable. Digitalisation, such as online postal self-sampling, can indeed expand reach, but this study also shows that OPSS users had a higher likelihood of experiencing unmet need. This means that technology does not automatically resolve inequality when face-to-face services are still needed for vaccination, PrEP, acute symptoms, asymptomatic screening among people who do not fit conventional risk profiles, psychosocial support, or complex clinical needs. 1 Therefore, a human rights-based response must reject an approach that merely counts the number of available services while ignoring who fails to enter the system. Foucault’s 2 perspective helps reveal that sexual health services always produce knowledge about bodies, while a human rights perspective demands that this production of knowledge must not turn into a mechanism of exclusion. The state and service providers need to ensure that digitalisation does not become a new form of social discipline that shifts the burden of access onto individuals, especially those who are poor, disabled, living in areas with limited services, asymptomatic and uncertain about whether they are entitled to testing, or uncomfortable with online services. These findings strengthen the need for service evaluation based on justice, community participation, and the mapping of local needs, so that sexual health is not treated as a privilege for those who are able to understand the system, secure appointments quickly, or fit recognised risk categories, but as a fundamental right inherent to every human body.
