The Only Gay Sexual Health Clinic in Ireland Has Been Closed for the Whole Pandemic

Ireland's only dedicated sexual health clinic for men who have sex with men has been shut for the entirety of the COVID pandemic, leaving more than 10,000 people without access to sexual healthcare.

Staff at the Gay Men’s Health Service (GMHS) in Dublin had long been working on precarious agency contracts. When the pandemic hit, many of them were redeployed elsewhere in the health system and never came back, leaving the clinic without staff. The result is long term closure, and activists have warned VICE World News that this could contribute to a sexual health crisis among the city’s gay population.

“I suspect we’ll be dealing with it for a very long time to come,” says Adam Shanley of community organisation MPOWER.

GMHS opened in 1992, nine months before Ireland even decriminalised homosexuality. The clinic is Ireland’s only dedicated, statutory sexual health service for men who have sex with men. It has acquired a status in the Irish capital comparable to that of 56 Dean Street in London, the city’s largest sexual health clinic. GMHS’ own reports show that in 2019, it served 11,652 unique patients, making it one of the largest sexual health clinics in Ireland. The clinic is thought to have seen around 2,000 patients before it shut in mid-March.

It has also been chronically underfunded for years. In 2019, it turned away 1,700 people due to lack of capacity, roughly 13 percent of its potential users. GMHS comes under the primary care division of the HSE, Ireland’s Health Service Executive. HSE reports and operational plans from 2018 took note of the funding issues. They mention a “financial challenge in the region of €13 to 14 million” (£11.28 to 12.15 million), as well as “uncertainty regarding financial resourcing” for the clinic’s programmes.

Sexual health services are routinely underfunded in Ireland. Reports from 2019 show that ten counties in Ireland didn’t even have an STI clinic, while other clinics reported waiting lists of up to seven weeks.

This neglect has contributed to Ireland’s contemporary sexual health crisis. “Going into 2020, we were facing a real crisis around syphilis numbers,” says Shanley of MPOWER. “And Ireland’s HIV acquisition rate was the highest it’s ever been.”

It was in this context, following years of hard campaigning, that activists had finally won €5.4 million (£4.6 million) in funding for Ireland’s PrEP programme in late 2019. PrEP is an antiretroviral medication which can be taken daily to prevent HIV acquisition. This funding was welcome, but activists pointed out that without “serious and sustained investment to improve and expand Ireland’s sexual health services”, the PrEP programme wouldn’t fulfil its potential.

Their warnings proved prescient once the pandemic hit.

Last week, activists from Act Up Dublin staged online events to protest one year without the GMHS. Since the onset of the COVID-19 pandemic in March 2020, the clinic has remained firmly shut to the general public for its holistic array of supports, including screening, counselling, and vaccination.

The only part of the service that has been partially maintained has been the PrEP programme, consisting of around 1,000 users according to the clinic’s 2019 report. But the approximately 10,000 other men who ordinarily rely on GMHS services have been left without their usual port of call.

“Smaller hospital-based clinics don’t come close to matching the capacity of the GMHS, and so cannot fill the gap it has left behind”, says Andrew Leavitt, an activist from Act Up Dublin. The Mater PrEP clinic in Dublin, for example, is resourced for only 1,500 visits per year, and was already at capacity before the onset of the pandemic. These hospital-based clinics have also been impacted negatively by COVID, reducing the number of patients they were able to see.

Officials have been labouring under the delusion that people have not been having sex during the pandemic unless they’re cohabiting monogamous couples. The HSE officially recommended people “only be sexually active with someone you live with”. But the fact is, as reports from Ireland have highlighted, people are having sex anyway. This begs the question: where have the thousands of former GMHS users accessed sexual health support over the pandemic?

Currently, the primary pathway for someone with a symptomatic STI to obtain treatment is to get a diagnosis and referral from a GP, costing upwards of 60 euro. Many vulnerable people either do not have GPs or cannot afford the visit. But it’s also problematic for other reasons. 

“If you interact with a GP who doesn’t understand the sexual landscape of a gay man, that can end up doing more damage than good,” Shanley said. “You can experience a lot of shame at a GP’s office”. This is why the GMHS’s integrated, culturally aware service is so essential, as it understands the specific needs of users, including the trans community.

Shanley launched a HIV self-test kit during the pandemic to help alleviate some of the demand. “I had stock for a full year and it was all gone within ten days”, he says. “We’re seeing a significant rise in the number of guys reaching out to us”. The HSE also piloted sh24, an STI home-testing kit, which sold out in hours, indicating that demand for STI testing is desperate, with people unsure where to seek help.

One Dublin gay man, who relied on the GMHS for testing, reported waiting two months with symptomatic gonorrhea before he found access to a clinic last October. “I kept looking up places where I could get tested but it was gonna cost €100 to €200 so I couldn’t afford that,” he told VICE World News under condition of anonymity.

He was unable to gain access to the first hospital-based PrEP clinic he contacted. Eventually, another hospital clinic gave him an appointment. While some pathways to treatment exist through community organisations like MPOWER, many men are not aware of all their options.

Leavitt, of Act Up Dublin, says that gay men have reported “self-diagnosing and self-treating with antibiotics” over the pandemic, due to the difficulty of getting treatment. This is highly problematic, with the potential for misdiagnosis and even antibiotic resistance occurring. 

It's understandable that doctors of infectious diseases would be redeployed as medics and consultants on COVID-19 wards, but similar sexual health services in other large European cities have managed to stay open. London's Dean St. clinic remains open, even for walk-in clients. Similarly, Paris's Le190 clinic and Berlin's Checkpoint clinic remain open by appointment and video consultation. Even other clinics around Ireland have opened cyclically, in periods of loosened restrictions.

So, why did GMHS close to the public for a year? The hidden problem at the clinic is one of bad labour economics, and it is symptomatic of a system-wide problem in Ireland’s health service. VICE World News has learned that the GMHS relied almost exclusively on precarious agency contracts to staff the clinic. Despite being trained by the clinic, gaining essential cultural competence in dealing with the unique health needs of Dublin’s gay and bi men and trans community, and building important relationships with service users, staff were never provided with permanent roles.

When the pandemic hit, these agency staff were redeployed to assist with the COVID-19 response and many were offered permanent positions in health services elsewhere. As a result, the clinic was left without staff to rehire, and was unable to re-open.

“They lost very valuable long-time staff at the clinic, with experience, knowledge, and relationship with the community”, says Leavitt of Act Up Dublin. 

Speaking under condition of anonymity, a former nurse who worked for years at GMHS, until as recently as 2019, said working there “felt transient”, with ongoing uncertainty about “whether you’d be there next year or not”. The nurse left the clinic in 2019 when a permanent position was offered in another sexual health service.

“None of us were permanent, many were working as agency nurses, basically on zero hour contracts with no security, sick pay entitlements or pension and those with contracts were temporary”, the nurse said. “A lot of us were gay men, and we wanted to work there, we wanted to work for the community we were part of.”

“We were promised more stable contracts, but they never materialised. It’s a service that’s been there for nearly 30 years, it doesn’t make sense that they don’t have a permanent staff.”

Agency or locum contracts are more expensive for the health service, as they require a premium in the form of agency fees, on top of the actual wage costs. In a statement to VICE World news, Martina Queally, Chief Officer, HSE Community Healthcare East said: "Previously the GMHS relied heavily on agency staff. This is no longer the situation. The funding allocated to the HSE in respect of the GMHS PrEP programme was received in 2020 as recurring funding. This has facilitated a recruitment campaign to fill the posts for the GMHS PrEP programme to commence in the latter part of 2020. This recruitment is on-going.”

Queally also emphasised that existing PrEP patients continue to be seen, but reports indicate this is only about 1,000 users. As Act Up Dublin pointed out in a public statement, this means that functionally the service is still closed to the public.

The instability of work at the GMHS is symptomatic of a larger trend of casualisation of employment across the Irish health service. This trend began in the austerity years as health budgets suffered from fiscal tightening.

A 2017 study on the impact of austerity on Ireland’s health workforce found that permanent staffing was reduced as a supposed money-saving measure, but that “the reduction in directly employed staff was to a great extent matched by a marked increase in agency spending”. A report by the Irish Times in 2018 noted that the HSE was still spending “€800,000 a day on agency staff”, a figure which Sinn Fein leader Mary Lou McDonald described as “mind boggling”.

The amount spent on agency staff doubled in the last decade under Fine Gael governance, from €136 million in 2010 up to €355 million in 2019. The result of these failed savings measures is that even more money is spent, but work is just made more precarious. The HSE is now living with this austerity hangover. The Irish Nurses and Midwives Organisation have repeatedly claimed there is a recruitment freeze in place, and that the HSE refuses to hire the permanent staff it needs. The government denies the claims.

More recently, Fine Gael has been hit with wave after wave of health spending scandals, as it was revealed that in 2020 the HSE chief executive was paid more than the president of the United States, and as budget overruns led to the government unwittingly building “the most expensive hospital in the world”. Soon after, the coalition government of Fine Gael, Fianna Fail and the Green Party, voted down a bill to pay student nurses.

The consequences of the inadequate resourcing and staffing of the GMHS are potentially huge. Ireland was already experiencing HIV and syphilis crises among men who have sex with men before the year-long closure of services.

“Often, the majority of STIs are asymptomatic”, Shanley points out. “STI figures from 2020 only fell by a little, but testing fell by a lot. That would indicate that onward transmission of STIs, including HIV, are now running at much higher rates than normal. I suspect we’ll be dealing with it for a very long time to come”.

The mood among activists and frontline workers is that this dire situation could have been avoided if sexual health services had been properly resourced and staffed at a national level.

As Shanley puts it: “Over nearly three decades, those at the GMHS have carved out a safe and compassionate space for us to maintain good sexual health, despite having to do it on a shoestring. We deserve a space like that, and they deserve the resources to see it through another three decades.”