Insights into Sexual Health Trends and Attitudes
Dive into the evolving landscape of sexual health with a focus on STIs, screening, and societal perceptions. Explore shifting attitudes towards sexual behavior, relationships, and gender dynamics based on recent surveys and case discussions. Gain knowledge and skills in sexual history taking, data gathering, and health promotion within a GP setting.
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Recap CTG modules 1-2 Sick notes and benefits Calgary Cambridge framework Role play - explanation Waiting for God caring for the elderly Case scenarios based on EOL care Role play active listening and empathy
CTG modules 4-6 Spring dates 2019 Module 4. A different planet - teenagers/adolescents Module 4b Sharing management 12/13th March 2019 Module 5. Walked into the door Domestic Violence Module 5b Dealing with Uncertainty 30thApril/ 1stMay 2019 Module 6. They are different to us . Learning disability and Vulnerable adults. Module 6b Medical Ethics 21st/22nd May 2019
Module 3a 27th November 2018 Name check and housekeeping. Sexual health and sexuality Presentation and case discussion Coffee Case discussion/ role play Module 3b Case scenarios based on 3a Role play on sexual health/ data gathering.
Closing the Gap 2018 Dr David Anderson With thanks to Dr Andy Downs
Quick clip Apologies if some are near the knuckle . https://www.youtube.com/watch?v=XppEzopIahs
Aims of 3a Improved knowledge of STIs, screening and health promotion Develop skills in sexual history taking in a GP setting Improve skills in data gathering, by using cases involving sexual health.
Sexual health survey 2014 Shift in attitudes: Average number of male partners, a female has increased from 3.7 in 1990 to 7.7 in latest survey (8.6 to 11.7 for men in same period) Sharp rise in proportion of women having had a sexual experience with another woman - 1.8% in 1990 to 8% in the survey Around 50% of men and women say there is nothing wrong with same sex relationships The is greater acceptance of one night stands but less acceptance of cheating (sex when in exclusive relationships)
Sexual Health 2014 Britons are having sex less often Median number of occasions of sex in previous 4 weeks decreased from 5 in 1990 to 3 in 2013. Infections: 16% of women tested had HPV (the virus causing genital warts and linked to cervical cancer) 1 in 100 women (15-44) had chlamydia Increase in HIV testing - from 8-9% in 1999 to 17-29% Attendance at STI clinics from 6.7 to 21.4% in women and 7.7 to 19.6% in men.
Sexual health 2014 Sexual loss of function Affects 30% of women and 15% of men Difficulty reaching climax 16% Vaginal dryness 13% Premature ejaculation 15% Erectile dysfunction 13% Sexual loss of function is associated with depression. Loss of sexual function also associated with previous STIs and also non-volitional sex.
Non-volitional sex Sexual activity against a patient s will Affected 9.8% of women and 1.4% of men Median age was 18 for women and 16 for men Less than half of women and less than 1/3 of men had told anybody about it fewer still had reported this to the police (8-12%) Persons responsible for this was a stranger in only 15% of cases. Associated with STIs and also teenage pregnancies.
Primary Factors in Taking a Sexual History Ensure privacy and confidentiality Establish rapport Accurately define the problem(s) Ensure successful patient management Diagnosis and treat symptomatic disease Detect asymptomatic disease Prevent serious sequelae, (i.e. infertility in women) Promote behavior changes to prevent future infections
Introducing the Sexual History Acknowledge personal nature of the subject matter Emphasize confidentiality Stress health issues related to sexual behaviors Be able to explain how the information will help you care for the patient I m going to ask some questions about your sexual history. I know this is very personal information, but it involves important health issues and everything we discuss is confidential
Communication Skills to Facilitate the Sexual History Use open-ended questions rather than leading or yes/no questions Who, what, when, where? Tell me about Cone Style of interviewing Encourage patients to talk, when needed Permission-giving: Say it in your own words Give range of behaviour (!) and ask for patient s experience Active listening cues to urge patient on Eye contact, nodding, Yes, go ahead
General Considerations for Taking a Sexual History 1 Make no assumptions Ask all patient about gender and number of partners Ask about specific sexual practices Vaginal, anal and oral sex Be clear Avoid medical jargon Restate and expand Clarify stories when necessary
General Considerations for Taking a Sexual History 2 Be tactful and respectful Use an unrelated translator whenever possible Use accepting, permission-giving language and cues Be non-judgmental Recognize patient anxiety Recognize our own biases Avoid value-laden language e.g. ( You should.. , Why didn t you.. I think you.. )
Video clip Case scenario
Thoughts ? In small groups (2-3), discuss your thoughts about this video.
Sexual History Content 1 Chief complaint General health history Allergies Recent medication Past STDs Women: brief Gynae history HIV risk factors (IVDU, partner s status) HIV testing history
Sexual History Content 2 Past and current sexual practices Gender of partners Number of partners Most recent sexual exposure New sex partners Patterns of condom use Partner s condition Substance abuse Domestic violence issues
Summary: The Five Ps Past STDs Pregnancy history and plans Partners (Sexual) Practices Prevention of STDs/HIV There are probably additional questions that you need to ask appropriate to each patient s circumstances.
Risk reduction If the patient is in a monogamous relationship lasting more than 12 months, risk reduction counselling may not be needed. However you may need to challenge monogamy, condom use and perception of risk depending on the circumstances. Remember to reinforce positive behaviour such as risk reduction, safe sex and contraceptive practice where appropriate.
Ravi Male aged 22. presents with 4 days of dysuria and no testicular pain.
Ravi Does he have a UTI ? Or could it be a STI ? What are you going to do Take a history, sexual hx, PMH and examine penis/ testicles think warts and ulcers as well. Increased risk of a STI if under 35, sexually active and recent partner change. Also MSM and/ or unprotected SI.
Ravi Urethral discharge think chlamydia, gonorrhoea and NSU. Dysuria and discharge more likely to be gonorrhoea. Dysuria and no discharge probably chlamydia. Refer GUM clinic for pre-treatment culture and partner screening/ treatment. In men first pass urine and more than 1 hr. since last micturition. In women, ideally swab or urine test.
Chlamydia Incubation window = 2 weeks after last UPSI Treatment: Azithromycin 1g as single dose Doxycycline 100mg bd for 7 days Erythromycin 500mg bd for 14 days if pregnant And no sex for 7 days (or until partner treated) Usually no need for repeat testing unless pregnant But under 25s advised to have another test after 3 months due to risk of new infection.
Genital warts Warts can be red/ fleshy or keratinized (skin colour) HPV infection is common Often asymptomatic Incubation is variable and can be carried for years.
Genital warts treatment Clinical diagnosis and can be treated in primary care 30% of warts disappear spontaneously within 6 months. Self applied treatments: 1. podophyllotoxin 0.15% cream (warticon) for 4 weeks useful if soft external lesions (not anal) 2. imiquimod 5% cream (aldara) for hard and soft extenal warts. Use for 3 days (M/W/F) Review every month for 4 months. Cryotherapy nitrogen every 1-2 weeks
STI cases - Helena 31 years old lady with recent offensive vaginal discharge on the pill after having had 2 children. Married for 8 years husband works away a lot. Thinks it is thrush again wanting cream
Helena Is this candidiasis or physiological What are the other possibilities ? Careful sexual hx and nature of discharge. Associated pain/ dyspareunia and pv bleeding. When did she last have sex and has she had sex with anybody else. Risk of pregnancy ?? Physiological discharge is white/ clear and non offensive, alters with menstrual cycle.
Helena STIs. Chlamydia can cause copious purulent vaginal dx but asymptomatic in 80% of women Gonorrhoea purulent vaginal dx but asymptomatic in 50% of women Trichomonas vaginalis offensive yellow dx which is frothy and often profuse causing vulval itch and soreness, dysuria and superficial dyspareunia. Common in young women and Rx = MNZ 400mg bd for 1 week. Treat current partner and any partner within 4 week period. Refer GUM clinic screening for above, HIV and syphilis.
Candida Candidal infections are common but probably over diagnosed and over treated. Itch due to overgrowth causing vulvo- vaginitis thick, white dx which is non-offensive and can cause soreness and dysuria/ dyspareunia. 10-20% women are asymptomatic often found incidentally on swabs - treatment not needed. Intravaginal antifungal creams/ pessary for uncomplicated infections Clotrimazole 1-2% cream topically, if vulval symptoms, for 7-14 days Do not routinely treat asymptomatic sexual partner.
Bacterial vaginosis Bacterial vaginosis is more commonly seen in sexually active women but is not a STI thin profuse fishy smelling dx without itch/ soreness. Often asymptomatic and treatment not normally required unless undergoing TOP (CKS) or IUD insertion. If symptomatic, prescribe metronidazole 400mg bd for 5-7 days. Alternative is intravaginal MNZ (0.75%) gel for 5 days or intravaginal clindamycin (2%) cream for 7 days. No need for test of cure (BASHH) Avoid bubble baths/ shampoos in the bath.
Vaginal discharge Take a clinical and sexual hx. Consider STI if new or > 1 sex partner in the past year. If risk of STI, refer to GUM or do triple swabs - high and low vaginal swabs, endocervical for chlamydia. Diagnose candida or BV clinically do not send swabs (unless recurrent infections). BV > 50% cases. Consider vaginal swabs if: Postnatal, post miscarriage/ TOP/ surgery Recent coil insertion, vaginitis without discharge Recurrent sx (4+ per year), previous treatment failure
Olivia 27 year old female c/o dysuria so given 3 days trimethoprim at UCC but no better and getting worse. Urine dip WCC ++ but no blood/ nitrates. What do you think is going on ?
Genital ulcers Herpes simplex infection HSV 1 0r 2 Mouth or genital infection Oral antivirals are primary treatment Aciclovir 400mg tds for 5-10 days, starting within 5 days or while new lesions are forming (BASHH say 5/7 Rx) Ideally refer to a SH clinic, especially if suspect HIV. But can treat in primary care if referral is declined No cure average 4-5 attacks in first year after initial episode. Avoid orogenital sex if lesions are present. But can transmit infection when no symptoms.
Gary 30 year old man MSM Presents with mild widespread rash Also mild fever, malaise and sore throat Generalised lymphadenopathy on examination.
Widespread rash including palmar ulcers .
syphilis Secondary syphilis develop 6 -8 weeks after primary infection (single sore, incubation = 9-90 days, heals within 1 month). Non-itchy rash with rough reddish-brown spots on soles and palms. Rash present for 1-2 weeks need high index of suspicion. Blood test (serology) will be positive in secondary stage. Refer to SH clinic could be open to prosecution if having sex with contacts with known diagnosis of syphilis Treatment is IM penicillin.
STI top tips Urethral dx think STI, especially if under 25 yrs. Acute vulval pain think HSV Genital ulcers think herpes simplex or syphilis Arthritis think chlamydia/ GC Viral illness with rash think primary HIV, especially MSM. Lower abdo pain exclude ectopic/ appendix. Think PID. Swollen painful testes in young man exclude torsion, then think STI Vaginal dx in young women think BV if odour, no itch.
https://www.youtube.co m/watch?v=mxlZD3oEfs U&list=PLzmtTg5wGBW XwezQxPkpYEskce1prAi VJ&index=56
Role play Small groups of 3 One to act as observer Work through the following case(s) Feedback as a whole group
Case 1 - Ben An 16 yr old man attends. He tells you that he has been passing razor blades for the last few days and has a discharge from the end of his willy . Discuss! Issues? Attitudes? Thoughts about how to approach this?
Case 2 - Debbie Case a 25 yr old woman attends. She tells you that she has had unprotected sex 2 nights ago and would like the morning after pill . You recall that you referred her husband for a vasectomy last year. Issues? Attitudes? Thoughts about skills to use?
Case 3 - Ryan A 26 yr old man attends, who has not attended often at all in the past. The only 2 consultations in the last 5 years were for a wrist injury & a sore throat. He tells you that he booked the appointment today as he has had problems with maintaining an erection ever since his 1st sexual encounter. He tells you that he is heterosexual. Discuss
Discuss the following cases? Or would you like to do more role play?
Case 4 Nicola A 35 yr old woman attends. She tells you that she is finding sex very painful for the last 9 months. She is now finding it difficult to relax when she has sex, and is avoiding it whenever possible. She tells you that she had pelvic inflammatory disease some years ago, but that the problem seems to be more at the opening now. Discuss
Case 5 - Chloe A 24 yr old woman attends. From the notes you can see that she has had 2 TOPs in the last 3 years. There is a previous history of chlamydia infection last year. You note from the records also, that there has been no consultation for contraception in the last 9 months. After the usual introductions, she tells you that she has come today to request an abortion . Discuss
