Abstract
An increase in the rate of sexually transmitted infections (STIs), particularly Chlamydia, and an unacceptably high level of teenage pregnancies led the UK Government to identify sexual health as a new priority public health area in their 2004 White Paper ‘Choosing health: making healthier choices easier’. The sexual health assessment is an essential tool for the GP, which will direct the need for further investigation and/or treatment for sexual health problems. However, there is still significant stigma associated with many sexual health issues. Because of the sensitive nature of this topic, patients may feel embarrassed and experience additional anxieties when presenting to their doctor. This article aims to provide a framework for performing a thorough but sensitive sexual health assessment in primary care.
The GP curriculum and sexual health
What is sexual health?
Sexual health can be defined as ‘Enjoying the sexual activity you want without causing yourself or anyone else suffering or physical or mental harm. It is also about using contraception and avoiding infections’ [Royal College of General Practitioners (RCGP) Curriculum statement 11]. It is a clinical topic that encompasses several lines of practice, most of which will be conducted in primary care, such as the majority of contraceptive services and cervical screening. Other sexual health issues that the GP may face on a regular basis include the presentation of symptomatic and asymptomatic STIs and other genital tract infections. Sexual health also includes gender-specific health issues.
Epidemiology
The five most common STIs in genito-urinary medicine (GUM) clinics in England are chlamydia (91 075 cases), genital warts (75 615 cases), herpes (29 703 cases), gonorrhoea (16 145 cases) and syphilis (1858 cases). The number of new cases of STI increased by 21% in the 10 years between 2001 and 2010 [Health Protection Agency (HPA), 2011].
The prevalence of STIs is highest in those under the age of 25 years, with 65% of chlamydia infections, 50% of gonorrhoea infections, 55% of genital warts and 43% of new genital herpes infections occurring in this age group in 2007 (HPA, 2008a). Just over 1 in 10 young people presenting with an acute STI at a GUM clinic will become reinfected with an STI within a year.
Men who have sex with men
Men who have sex with men (MSM) are a high-risk group for STI with 66% of syphilis infections and 36% of gonorrhoea infections occurring in this group (HPA, 2008b). Unlike for heterosexual men, rates of STI remain high even as MSM get older.
Under-18 conceptions
The UK's conception rates for girls under the age of 18 years and those under the age of 16 years fell by 11.7 and 13.3%, respectively between 1998, when the ‘Teenage pregnancy strategy’ was introduced in the UK, and 2008 (Family Planning Association, 2010). While the rates are now at the lowest level for the past 20 years, the UK still has the highest rates of teenage pregnancy in Western Europe. In 2008, there were 38 750 under-18 conceptions in the UK (40.5 per 1000 females aged 15–17 years), of which 49.7% resulted in termination of pregnancy. In the same year, there were 7123 under-16 conceptions in the UK (7.8 per 1000 females aged 15–17 years), of which 61.8% resulted in termination (Family Planning Association, 2010).
Epidemiology of contraception
Three-quarters of women under the age of 50 years use contraception. The condom has gained in popularity over recent years. In 2009, 25% of women cited it as their usual method of contraception; the same proportion that cited the combined oral contraceptive pill. Younger women are more likely to opt for combined hormonal contraception or the male condom, whereas older women are more likely to rely on sterilization of either partner (NHS Information Centre, 2009).
Sexual health history
To perform an adequate sexual health assessment, good communication skills are essential. This is important to aid the consultation and may be significant in improving health outcomes. Providing a comfortable and confidential environment will put patients at ease and give them the confidence freely to discuss sensitive issues, such as sexual behaviours. Having literature and posters that advocate confidentiality and a non-judgemental nature clearly displayed in the practice will offer reassurance.
The reception staff should receive training in how to deal with patients who present with sensitive issues who may not be comfortable disclosing the reasons for attendance to them. If a patient expresses reluctance to divulge the reasons for the appointment, this should be respected and no further questions asked. Patients should always be asked in private if they would permit a student or other observer to be present during the consultation. The wishes of the patient should be respected if the patient declines.
Screening for sexual health problems
It may be appropriate for those individuals considered to be at high-risk of developing STIs, or for those who exhibit risk-seeking behaviours, to carry out STI screening by the means of taking a brief core sexual history such as that outlined in Box 1 [National Institute for Health and Clinical Excellence (NICE), 2007]. A more detailed sexual history should then be taken in those who have a positive STI screen.
In areas where there is high prevalence (greater than 2 per 1000 people) of HIV, a HIV test should routinely be offered and recommended to all adults registering in general practice and all general medical admissions [British HIV Association, British Association for Sexual Health and HIV (BASHH) and British Infection Society, 2008]. HIV testing should also be offered to patients who present to primary care with conditions associated with HIV, for example, lymphadenopathy of unknown cause or oral candidiasis.
Initial assessment of presenting complaint
Guidance on how to take a sexual history for patients presenting with sexual health problems is outlined by the BASHH 2006 national guidelines. Initiate the consultation with open questions regarding the presenting concern or symptoms (Box 2). Once the reason for attendance has been established, more focused questioning should be used to ascertain the more specific nature of the patients' genito-urinary (GU) symptoms.
Core components of the sexual history.
Symptoms/reason for attendance Last sexual intercourse (LSI), gender of partner, sites of exposure, condom use Previous sexual partner (details as for LSI) Previous STIs For women: last menstrual period (LMP), contraceptive and cytology history Human immunodeficiency virus (HIV) and hepatitis B/C risk assessment Establish mode of giving results Establish competency/child protection concerns (if aged under 16 years)
Pursue lines of questioning regarding any associated GU symptoms. Document the site, the nature of the problem, the impact on the patient's life and sexual life and the timing and duration of symptoms. You should also ask if there are any other symptoms, such as painful and/or red eyes, painful joints or rashes. It may be helpful to do a systematic symptom review (Box 3). In some instances, this may reveal specific genital symptoms that have been overlooked or ignored by the patient. It is always worth concluding the sexual history by asking patients if they have any further concerns that have not been addressed.
Common presentations.
Genital skin conditions including rashes, ulcers and lichen sclerosis Anogenital lumps Abnormal genital smell Unusual or different vaginal discharge or penile urethral discharge Pain on passing urine in both men and women Testicular pain or swelling Pain on intercourse Intermenstrual bleeding Vaginal bleeding after intercourse Sexual dysfunction Reactive arthritis
Last sexual intercourse
In relation to the last time they had sexual intercourse (LSI), all patients should be asked some core questions. The gender of the partner should be ascertained. This is so that gay and bisexual men can be identified, in order to make a risk assessment and request appropriate investigations.
The type of sexual intercourse (oral, vaginal and anal) will identify sites from which samples should be taken. Patients should be asked about the use of condoms and other methods of barrier contraception during sexual intercourse and whether the condom was consistently used and remained intact. A note should be taken of the nature of the person's relationship with his or her partner (i.e. long-term partner, traceable casual partner or non-traceable casual partner) and enquiry should be made as to whether that person has exhibited any symptoms.
Symptom review.
Change in vaginal discharge Vulval skin problems Lower abdominal pain Dysuria Change in menstrual cycle or irregular bleeding
Urethral discharge Dysuria Genital skin problems Perianal or anal symptoms (in gay men)
Previous sexual history
The same line of questioning should then be extended to previous partners. Details of all partners within a period of 3 months should be acquired. A risk history of this duration should identify if the patient has potentially been exposed to HIV despite having a negative HIV antibody test.
In patients exhibiting symptoms of an STI, the sexual history should be taken for the incubation period of the STI that may be responsible for the patient's symptoms. Men should also be specifically asked if they have ever had sexual intercourse with another man, had sex abroad or paid for sex.
Previous STIs
All patients should be asked about any previous history of STI. If a person has had a previous STI, details of each episode should be recorded. In those patients who have had syphilis, the stage of syphilis, the treatment received and the centre at which treatment was started should be documented.
Contraceptive and reproductive health history
Women of childbearing age should be asked about past and current contraception. The date of their LMP should be noted along with details of their usual cycle (i.e. length, regularity). This is so that pregnancy or risk of pregnancy can be identified in order that contraindicated drugs can be avoided and appropriate contraceptive advice given. The date of a woman's last cervical smear should be recorded along with the outcome. For those patients whose smear test is overdue, this can be offered.
An obstetric history should be taken from all women. Enquire about fertility history, e.g. has she been actively trying to conceive, or ever experienced any problems with this, any pregnancies (live births or miscarriages), the age at which she first conceived and any terminations.
Past medical and surgical history
Once the sexual history has been taken, enquire about any other relevant components of the person's general medical history. For example, past medical and surgical history may identify conditions that may be associated with or influence the management of sexual health issues.
Drug history and allergies
Record details of past and current medication. Patients should be asked about allergies, especially to antibiotics. If they have an allergy to a particular antibiotic, then the type of reaction should be noted.
Risk assessment
A risk assessment should be performed for all patients in order to identify those individuals who are at a high risk of acquiring an STI on the basis of their sexual history. In addition to those attending with suspected STI, GPs should be proactive in conducting opportunistic screening for STI risk in patients who attend for consultations on other matters such as:
contraception pregnancy and termination cervical smear test travel advice and/or immunization gynaecological or urogenital problems
A risk assessment could also be performed when a new patient registers at the practice. This could be done either in the form of a one-to-one consultation or by means of specific sexual health-related questions within a generic health screening questionnaire. An advantage of the latter method is that patients will not feel as if they are being singled out and should freely divulge relevant information without feeling intimidated.
NICE (2007) identifies MSM, and individuals who come from or who have visited areas of high HIV prevalence, as being at high risk of acquiring STIs. In addition, these guidelines specifically identify behaviours which increase the risk of acquiring an STI including:
the misuse of substances and/or alcohol the early onset of sexual activity having unprotected sex the frequent change of or multiple sexual partners
In order to identify those patients who are at risk of hepatitis B and C, current or past history of injecting drugs and sharing needles should be established. Those patients at risk of hepatitis B (sex-workers, gay men and intravenous drug abusers) should be asked to provide vaccination history. This will identify those who need testing and/or vaccination.
Young patients
Assess patients who are under the age of 16 years who present with a sexual health issue with regards to their competency to consent to history taking and examination. The local child protection team should be contacted if there is any concern over the child's welfare.
A preliminary assessment should be made to ascertain the need for further assessment. Ask, if relevant, if the child's parents or carers are aware of his or her sexual activity and attendance at the clinic. The child should be asked if he or she has ever had a sexual encounter against his or her will. The age of the partner should be noted and an assessment of vulnerability made (e.g. alcohol and drug misuse, self-harm or a history of psychiatric illness).
Sexual intercourse with a child under the age of 13 years is considered statutory rape. When sexual activity is reported by children under the age of 13 years, an assessment should be made as to whether the child is at immediate risk. If your judgement is that the child is at immediate risk, then you must contact the local child protection team or the police straight away and before the child leaves the premises to discuss your concerns. In cases where there is less urgency, the matter should be discussed within the practice team and in confidence with the local child protection team. The specific nature and circumstances will determine if social care and/or police involvement are required.
Patients aged under 18 years and who are from disadvantaged backgrounds, who are in or leaving care or who have low educational attainment may be especially vulnerable. Once a patient has been identified as being particularly at risk, the GP should take steps to provide sexual health advice on how to prevent and/or how to get tested for an STI and the full range of reversible contraception, including emergency contraception. For those young individuals who are pregnant or already mothers, referral to the relevant agencies who can assist with integration into education and employment should be made.
Further assessment
The majority of patients who present with a history of possible STI should be actively encouraged to attend the local GUM clinic for appropriate further investigations, treatment and advice. While the management of an STI is not beyond the remit of the GP, patients who have sought medical attention for a particular STI may be at risk of others, and therefore, a GUM specialist should ideally be involved in the patient's management.
If a patient that you suspect from the history to have an STI refuses to attend a GUM clinic or you feel that your patient is unlikely to attend, it is important to perform an appropriate examination and investigations in primary care. Explain the need for clinical examination and testing clearly to patients and also outline what you propose to do before the examination is started, thus giving the patient an opportunity to decline.
All practices should have a chaperone policy in place as this is beneficial for both patients and staff. If a chaperone is requested but unavailable, the examination should be deferred. If the patient declines a chaperone, this should be documented and the examination carried out only if the GP feels comfortable doing so.
When examining a patient with a suspected STI, check the external genitalia along with the perianal region. Then examine the groin for lymphadenopathy. Consider a rectal examination in patients who have anal symptoms or report anal intercourse. For women, perform a pelvic examination and a vaginal speculum examination taking triple swabs at the same time. These consist of:
Swab 1: high vaginal swab taken from the posterior fornix. This is tested for bacterial vaginosis, Trichomonas vaginalis and Candida
Swab 2: endocervical swab and testing for gonorrhoea Swab 3: endocervical swab testing for Chlamydia (a special swab is required)
David Mack/SPL
Other investigations that can be performed in primary care include:
pregnancy testing cervical screening urethral and/or anal swabs for men (including Chlamydia swabs if indicated) anal swabs for women oral swabs viral swabs for genital ulcers (special swabs are required) and urinalysis (in addition to the usual microscopy, culture and sensitivity, Chlamydia testing can also be performed using urine samples in some areas) Blood testing for hepatitis B and C and HIV
The way in which patients can expect to receive their results should be explained, when tests are taken, along with the anticipated time frame in which results may become available.
Sexual contact tracing
Sexual contact tracing is a sensitive and emotive issue. While this is a process that is usually conducted through a GUM clinic, the GP may become involved. To facilitate contact tracing, enquire about partner notification during the initial consultation in the eventuality that tests may come back positive for STI.
The utmost care should be taken to preserve the confidentiality of patients and their contacts. Under no circumstances should you reveal the identity of the index patient to the contact, even if the contact demands to know. Tact and diplomacy are needed if inviting an identified contact of an infected patient to attend the practice without being aware of the reason for attendance.
If the patient refuses to inform sexual partners, this poses a dilemma for the GP. Advise the patient that infected partners who have not received treatment are in danger of harm and also risk re-infecting the index patient and/or other people. In instances where there is serious risk posed to the partner, for example, if the patient has a diagnosis of HIV, the General Medical Council (GMC) suggests that it may be appropriate for the GP to disclose information to the partner without the patient's consent. If this is required, ask for advice from your defence union, inform the patient before any information is disclosed and be prepared to justify your decision.
Key points
Patients presenting to their GP with genital tract infections may exhibit an array of symptoms A relaxed but confidential setting is necessary for the consultation The GP needs to be tactful and display good communication skills in order to take an adequate sexual history, paying attention to the patients' body language when asking sensitive questions The sexual health assessment should begin with open questions, which will lead to more focused closed questions once a rapport has been established Examination should be performed with a chaperone present The GP should provide details of how and when the patient can expect to receive results