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Sexual Health Dr Fiona DuffIntroductions and ground rules Aims • Understand the UK healthcare system, professionals, and the roles they play in providing patient care in field of sexual health • Become aware of the best practices for delivering sexual health advice, services and treatments specific to the UK setting • Develop effective communication techniques when discussing sexual health issues with patients • Increase knowledge of legislation and ethical guidelines related to Sexual Health • Learn how to manage risks and the implications of advice provided in an evidence-based mannerCase 1 An 18 year old patient presents to your clinic who has had unprotected sex yesterday • What are her options for emergency contraception? • What are her options for contraception going forward? • What other factors would you consider re the risk of UPSI?Oral EC: both work by inhibition of ovulation – UPA more effective than LNG • Effectiveness difficult to study (ethics, hard to do RCTs) – studies suggest anything from 60-90% pregnancies prevented Copper IUD works by toxic effect sperm/ova AND inhibition implantation – can be used after fertilization • Most effective method – studies suggest >99% effectiveCase 1 An 18 year old patient presents to your clinic who has had unprotected sex yesterday • Consider need for STI testing – concept window periods • 2 weeks for swabs – GC/CT • 4-6 weeks for BTs – HIV/STS +/- hep B and C depending on risk Need for PEP if high riskCase 1 A 15 year old patient presents to your clinic who has had unprotected sex yesterday • What is the age of consent in the UK? • Ddecision?affect your ability to treat her? What factors would you consider in making yourCase 1 • The age of consent in the UK is 16 years old for males and females (Sexual Offences Act 2003) • Any sort of sexual contact without consent is illegal, regardless of the age of those involved. Children under the age of 13 cannot consent to any type of sexual activityCase 1 • Age 13-15? Consider the nature of the relationship: • Relative ages • Concerns re coercion or competence of the young person’s decision making If any concerns discuss with safeguarding lead +/- referral to childrens social services • The laws are there to protect children and not to prosecute under-16s who have mutually consenting sexual activity • Whilst the Sexual Offences Act 2003 recognises that mutually agreed, non-exploitative sexual activity between teenagers does take place and that often no harm comes from it, any sexual activity between an adult and a young person under 16 is a criminal offencem à to protect vulnerable under 16sGillick competence and Fraser guidelinesGillick competence and Fraser guidelines Gillick competence • Capacity of under 16s to consent to treatment • Children under 16 can consent if they have: sufficient understanding and intelligence to fully understand what is involved in a proposed treatment, including its purpose, nature, likely effects and risks, chances of success and the availability of other options. • As with adults – consent needs to be voluntarily given and not under undue pressure/influence • Children may be able to consent to some treatments and not others due to understanding needed for different treatments and fluctuating capacity e.g. in mental health conditions à decision specific • If a child does not pass the Gillick test, then the consent of a person with parental responsibility (or sometimes the courts) is needed in order to proceed with treatment.Gillick competence and Fraser guidelines Fraser guidelines (contraception, termination and treatment STIs) Practitioners using the Fraser guidelines should be satisfied of the following: • The young person cannot be persuaded to inform their parents or carers that they are seeking this advice or treatment (or to allow the practitioner to inform their parents or carers) • The young person understands the advice being given • The young person's physical or mental health or both are likely to suffer unless they receive the advice or treatment • It is in the young person's best interests to receive the advice, treatment or both without their parents' or carers' consent • The young person is very likely to continue having sex with or without contraceptive treatmentCase 1 A 15 year old patient presents to your clinic who has had unprotected sex yesterday • This patients mother calls the surgery and asks to speak to you about the content of the consultation. What do you do?Case 1 Confidentiality • Doctors, nurses and health professionals have a duty of confidentiality to patients of all ages, including under 16s • Important to reassure patients of this (esp under 16s) in appts • Only in exceptional circumstances may confidentiality be broken e.g, the health, safety or welfare of the patient, or others, would otherwise be at grave risk • Whenever possible, the patient should be informed before confidentiality is broken (eg. if informing safeguarding team), unless to do so would be dangerous to the patient or others (e.g. in some DV situations) • Doctors do not have duty to report crimes (with exception offences related to terrorism/FGM) however is possible could be liable if serious harm occurred due to failure to disclose Case 2 A 25 year old patient presents to GP following a positive pregnancy test and would like to discuss options for termination with you • What is the law surrounding this? What options are available in the UK?Case 2 1967 Abortion Act Abortion in UK is legal if performed by a) registered medical practitioner (a doctor), and that it is authorised by two doctors, acting in good faith, on one (or more of the following grounds (with each needing to agree that at least one and the same ground is met): • (a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or • (b) that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or • (c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or • (d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicappedCase 2 • Section 1 (2) also states that doctors ‘may’ take into account a woman's social circumstances/environment as factors that may impact her health • Both doctors do not have to see/examine the woman – can make decision based on information from their team • Abortions on basis sex selection not legal as not covered in terms of 1967 Act – abortion clinics will not scan for sex and if suspicious patient seeking abortion for this reason will refer to safeguarding agency • Doctors in UK can ‘conscientiously object’ – limited to actually taking part in procedure – must refer to colleague who is able to • Case in 2014 supreme court Glasgow midwivesCase 2 • GP can refer to termination services • Sexual health clinics can refer to termination services • Self referral to termination services Organisations providing varies by area – will signpost women to local services - no charge on NHS Case 2 Abortion pill: Mifepristone à blocks the hormone progesterone à lining uterus breaks down Misoprostol à womb contracts à cramping, bleeding and loss of the pregnancy like a miscarriage Up to 10w - since COVID can be at home 10-24w: in clinic for second tablet Surgical procedures: VA up to 14w – can be LA VA >14w and D and E under 18w - GA or sedation D and E over 18w - GACase 3 A 25 year old presents to your clinic with abnormal genital discharge • What would you cover when taking a history?Case 3 A 25 year old patient presents to your clinic with abnormal genital discharge Sexual history • Discharge – colour, smell, associated Sx e.g. itch • Urinary symptoms Hx sexual partners • Skin changes – rash, ulceration (inc UPSI/pregnancy • Sx systemic illness (fever, vomiting) risk) PMHx DHx (inc Men contraception) • Testicular pain, swelling, lumps Allergies SHx (inc substances Women • Bleeding (PCB, IMB) and SG questions) • Abdominal pain and dyspareunia Anyone having AI – rectal pain/bleeding/dischargeCase 3 A 25 year old presents to your clinic with abnormal genital discharge • What would you cover when taking a history? • How would you examine the patient (inc any necessary tests?)Case 3 Examination Male • Examination penis (inc foreskin), testicular exam, LNs, skin Investigations Swabs (NAATs, MC+S, slides) Female Urine dip • Examination vulva inc skin, palpation LNs Urine HCG • Bimanual exam (if suspected ectopic/PID) • Speculum examination (inc swabs) BTs (HIV/STS +/- hep B/C) • Abdominal exam Anyone having AI – external exam +/- proctoscopyCase 3 A 25 year old presents to your clinic with abnormal genital discharge • What would you cover when taking a history? • How would you examine the patient (inc any necessary tests?) • What could possible causes be? How would these be managed?Case 3 A 25 year old presents to your clinic with abnormal genital discharge • Depending on setting may have access to immediate microscopy, NAATs or MC+S swabs - if long delay for results may wish to treat empirically Candida: fluconazole PO, clotrimazole PV/TOP BV: metronidazole PO, lactic acid PV TV: metronidazole CT: doxycycline PO GC: ceftriaxone IMCase 3 A 25 year old presents to your clinic with abnormal genital discharge • Are sexually transmitted infections notifiable diseases? • What is the law regarding informing partners? Notifiable diseases • Acute encephalitis • Malaria • Acute infectious hepatitis • Measles • Acute meningitis • Meningococcal septicaemia • Acute poliomyelitis • Monkeypox • Anthrax • Mumps • Botulism • Plague • Brucellosis • Rabies • Cholera • Rubella • COVID-19 • Severe Acute Respiratory Syndrome (SARS) • Diphtheria • Scarlet fever • Enteric fever (typhoid or paratyphoid fever) • Smallpox • Food poisoning • Tetanus • Haemolytic uraemic syndrome (HUS) • Tuberculosis • Infectious bloody diarrhoea • Typhus • Invasive group A streptococcal disease • Viral haemorrhagic fever (VHF) • Legionnaires’ disease • Whooping cough • Leprosy • Yellow feverCase 3 A 25 year old presents to your clinic with abnormal genital discharge • All sexual health clinics will carry out partner notification in case of any positive result – however does require consent from patient (can be done anonymously) HIV If you’re having protected sex there’s no law saying you must tell your partners that you have HIV. It’s your choice whether you tell them or not. However, in England and Wales there’s a risk of being prosecuted for reckless transmission of HIV if: • you had sex with someone who didn’t know you had HIV • you knew you had HIV at that time • you understood how HIV is transmitted • you had sex without a condom, and • you transmitted HIV to that person.Case 4 A 16 year old female (at birth) patient presents to the GP and would like to discuss transitioning. He uses he/him pronouns and has been living as male for last 2 years and is keen to start hormonesCase 4 Gender dysphoria is a term that describes a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity • Was previously referred to as ‘gender identity disorder’ – removed from DSM-5 in 2013 to try remove stigma – some groups still feel inclusion in DSM stigmatising • Gender dysphoria can motivate some people to seek to transition from one point on the gender spectrum to another, changing social role and outward presentation and sometimes taking hormones or having gender-related surgery. • Can be experienced at any age – children may show signs of being interested in toys/clothes etc associated in society with opposite gender – but not all children who do this will go on to experience dysphoria – lasting and severe distress esp. around pubertyCase 4 A 16 year old female (at birth) patient presents to the GP and would like to discuss transitioning. He uses he/him pronouns and has been living as male for last 2 years and is keen to start hormones • From GP/sexual health can refer patients to specialist services – where they will be assessed with regards to range of possible treatments • Can include hormone therapy, certain surgeries, voice coaching and puberty blockers • Referral will involve a period of assessment over several appts – and will include looking at whether patients have ‘socially’ transitioned e.g. changing name, ‘living’ as the opposite genderCase 4 A 16 year old female (at birth) patient presents to the GP and would like to discuss transitioning. He uses he/him pronouns and has been living as male for last 2 years and is keen to start hormones • Age 17 and over – adult services: gender identity clinics - 9 in England – long waiting lists +++ - Tavistock and Portman in London currently has over 12k on list and seeing patients now referred in July 2018! • Age 16 and under – children and young peoples services – gender identity development services: in process of change following Cass review published in 2022 – following High court judgement Bell vs Tavistock in 2020 (overturned in 2021) • Concern specifically over children’s ability to consent to puberty blockers and hormones – as can have long lasting effects e.g. on fertilityCase 4 A 16 year old female (at birth) patient presents to the GP and would like to discuss transitioning. He uses he/him pronouns and has been living as male for last 2 years and is keen to start hormones • For this patient referral to GIDS – now being changed over from predominantly psych model à tertiary paeds model • May be offered puberty blockers (delay onset puberty whilst deciding if want to pursue hormone treatment) – possibly reversible • Hormone therapy – causes irreversible changes e.g breast development, voice deepening, poss infertility • Therapy – CAMHS may be involved along sideCase 4 Adult patients: • Counselling/therapy – may need support +/- referral to local MH services whilst on WL • Hormone therapy: after assessment by two different clinicians • Chest surgery: social transition 1 year, masculinizing hormones for 6m prior to referral • Hysterectomy: social transition 1 year – as after 2 years T (risk of endometrial hyperplasia) • Genital surgery: social transition 1 year Private clinics – variable in regulation and practice – many patients will also access hormones online – may not be having monitoring so NHS clinics e.g. 56T offer this and NHS services can offer advice to GPs on this sometimes Some surgeries not funded on NHS e.g. facial surgery or vocal cord surgery, breast augmentation so will always be done privatelyCase 4 • By law you are able to change your gender and title on most official documents without a gender recognition certificate (i.e. legal change of gender) – GPs/employers/banks etc can change on system • Passport requires letter from consultant confirming that change of gender is permanent (usually from specialist service) • Gender recognition certificates allow people to change birth certificate and get married as affirmed gender • Need GD Dx and living for 2 years – otherwise if no Dx living for 6 years • Need medical reports from 2 Dr/psychlogists with experience in field – difficult in practice to get • Large range of evidence to show living in affirmed genderQuestions?