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Just talking down clothing. Hi, good day, everyone. Thank you for joining today's event that's been hosted by the Widening Participation Medics Network and the I M G T U K. So this event is sponsored by the Medical Protection Society, which is one of the leading indemnity providers in the UK. That's especially equipped to cover international graduates. So this series in general is aimed at preparing you all for the lab exams as well as for clinical practice within the UK. And today we'll be discussing some of the key concepts and guidelines of sexual health within the NHS. So this is an important topic to understand from the UK perspective and especially to understand the laws of the culture and how these may vary as it can vary quite a lot internationally and it can be a common pitfall for many exam takers. Um So are presenter today is Doctor Fiona daughter who's a GP with a special interest in sexual health. If you have any questions at all throughout the presentation, just pop them into the chat and we'll get to them at the end. So I'll just hand you over to Fiona now. Okay. So Yeah, hi, everyone. Um, as Vicki, I said I'm Fiona. I'm a GP, qualified for two years now and working in West London, um, I've got an interest in sexual health and contraception. Kind of did a placement during my GP training. Really enjoyed it. And so kind of did a fellowship last year. I was working within a sexual health clinic kind of in West London. Um, and I continue to do sort of contraception now. So fitting coils and implants. Um So, yeah, so today I think I'm just going to be sort of talking through some kind of cases and scenarios. Um We can't, obviously it's, we can't interact some sense of um sort of, you know, seeing on screen and kind of speaking, but I will be kind of posing questions as we go along. So it's sort of stuff for you to kind of think about, think about what you might do or you know what you know, or no, don't know about the topic. Um And if I do kind of ask questions before I launch into it and feel free to pop kind of any answers or anything you think about in the chat. Um, don't worry if it's wrong, don't worry if you're not sure it's kind of just helpful to see. Um if people have got any idea about it was some idea. Um Just so I can kind of picture and go through. Um And yeah, if anything doesn't make any sense to go and I can see the chat. So just kind of pop it in there and questions as we go along, I'll also put questions at the end as well. Um We'll try stick to about an hour. I think there's four cases to go through. Some of them are a little bit longer and a bit more complicated. So, um if we run over, if people are okay with that, yeah, apologies, but I can um we'll see how we get on. Um So, yeah, so aims of today's session is to try and understand sort of sexual health within the context of the UK health kind of care system. Think about the professionals involved, thinking about the roles they play in providing care. Um We want to think about kind of best practice for delivering sexual health, both in of looking advice, treatments and sort of services as well. Um Think about how we might communicate with patient's in these scenarios. Um And then think about some of the law and kind of ethical guidelines that sort of surround some of this. Um And then think about how we would sort of apply the evidence and, you know, think about risks and everything when we're going through. Um So yeah, we'll start with the first case. Um So this would be a very common thing to see, I guess in G P or such a health um even in A and E you might come across this kind of applicable to a range of places. So, an 18 year old patient comes in to see you and she's had unprotected sex yesterday. So, and yeah, I feel free to pops up in the chat. Um, what might her options be for emergency contraception? Is there, is there anything that you can think about? Um, what might her options be for contraception going forward? Um, and what other factors would you consider the fact that she's had unprotected sex? What other things might you think about? I'll give like 30 seconds if anyone wants to pop anything in the chat. No, not so much they'll go through. That's fine. That's okay. Um So yeah, emergency contraception. Um You might people refer to it as kind of the morning after pill. Um, because I guess that's what people have heard of. So, yeah, I can see someone mentioned Ello one pill or Copper Coil. Um, so yes, there are two main types of the morning after pill. Um, and actually they can be taken as you can see from the kind of got, they can be taken from more than just the morning after. So, um, from the time of when someone has unprotected sex. Um, so Levon L um, or sort of levonorgestrel and that's one of the pills that you may see that can be taken for up to 72 hours after someone has had sex, but it's more effective the sooner it's kind of taken. Um, and then, um, Uber Crystal, which is another type of morning after pill, um, that can be taken for up to 100 and 20 hours, kind of after the sex has sort of taken place. Um, you may see kind of different brand names in different countries. Um, and with Ella one, um, that is basically the Uber Crystal, the crystal one, the second one. Um, I can't remember off the top of my head. Now, I think the common name, I think it's 11 L is the sort of name for the leaving a gesture one that you see, um both the pills basically work by inhibiting ovulation. Um So they sort of involved, kind of, you know, hormones related to sort of progesterone. Um So they're only really deemed to be effective if a woman is at her appointment cycle before she populated, there may be some mechanisms by which they work after ovulation. But these are kind of less understood and sort of less of studies. So, you know, basically, if you take an average woman, you've got a 28 day cycle. So day zero, day one is when you start your period, day 28 is just the day before your next period is coming. Most women will love you later around day 14. So depending on where she is in the cycle, you know, if you're before ovulation, great, because you're going to kind of push ovulation back and that's that's kind of how it works. If you're after she's already ovulated, it may not be as effective, but you can still give the morning after pill kind of even at that time. Um, in the UK, both of these tend to be available from pharmacies as well. So, um women may access them kind of that way. Um Other things to consider with Levon L, um you've actually got to double the dose. Um If someone has kind of got a raised, am I? Um and of the two, we consider Ulipristal, so L1 to be sort of more effective, but with that one, it will be less effective if a woman has been on a type of contraception recently that contains progesterone. So say she's on the progesterone, any pill or the combined pill and the reason she's concerned about sort of unprotected sector, she's maybe missing doses. Um If she's had the pill kind of recently, you know, within the last kind of five days, you'd be concerned that it would cause the sort of a low pistol to not be as effective. So that's another consideration obviously as well, like with any sort of medication that's taken all, really, if people kind of vomit within, you know, an hour or two of taking it, they may need to have a dose against that sort of won't be effective. Um The studies are a bit difficult. I think I was looking this up and you know, some studies say they're sort of 60% effective. Some say up to 90% it's obviously really difficult thing to do kind of trials on because in most situations when women want the morning after pill, um they, you know, don't want to get pregnant. So giving a placebo wouldn't really be ethical. Um So yes, that's the kind of oral options. Obviously put any questions in the chat if there are. Um and then the other option would be the copper coil as mentioned. So that is by far the most effective form of emergency contraception. Um And you know, if it's used kind of within the right timeframe, um it's kind of up to over 99% effective at stopping pregnancies. Um The way it works is the copper that's in the coil is toxic to sperm and toxic to eggs. Um So it will work, you know, before the sort of, you know, has taken place. Um But it will also have effects kind of after fertilization. So after the sperm and egg have met before they are going to kind of implant within the wall of the womb. Um The toxic, the toxicity of the corporate kind of also causes irritation of the womb lining and it will make it very difficult for sperm and egg to implant. Um So, yeah, it can be used basically within five days of any unprotected sex and they're sort of other caveat to that is if you can work out exactly where a woman is in her cycle. You can also use it within five days of the ovulation. So, like I said earlier, day, zero, day one stop the period, day 28 just before your next period, day, 14 ovulation, you can use it up to day 19 kind of inner cycle. Um And obviously, the copper coils will go on to discuss, it can be used as a form of ongoing contraception as well. Um And we'll discuss some of the kind of pros and cons of that kind of going forward, but that's by far the most effective method, obviously, with that, it depends on having somewhere that can actually fit the coils. So that would usually be in the sexual health kind of clinic. And you've got from when the unprotected sex kind of starts, you've got those five days. So what might sometimes be the case is women would go to a pharmacy or see the G P, um, maybe have the kind of one of the pill options. Um But if they wanted to go and have a coil fitted, then that would be kind of the most effective and you can do both of the kind of failed safe sort of together. Um And so the next move on to kind of options for contraception kind of going forward. Um So there are lots and lots of different options. Um This slides probably slightly kind of hard to see. Um, I think we don't have time today for me to go through all of them in kind of huge amount of detail. Um, but I guess a good way to split them and this website, um, it's one called sex wise that you can just Google and it goes to everything really nicely and it's got really good, um, kind of leaflets that you can both center patient's, but also use to kind of revise yourself. If you go along the top, it's got sort of more of the long acting methods. So that would be things people don't have to remember to do every day or to do every time they have sex. So, um starting from the left, there's the implants which is a kind of progesterone pain containing small plastic tube that sits in the upper arm can be used for up to three years is, you know, again, really effective over 99%. Um There's two types of coils. So the IUD or the copper coil that we just discussed, which works basically from the toxicity of the copper. Um and the sort of irritation of the womb lining. So, implantation can't happen. Um It's, you know, you'll still have a regular period on that. It doesn't sort of affect your cycles like progesterone can do, but women may find it appeared get a lot heavier or a bit longer and more painful. So, not maybe right for women who've got really heavy periods. Anyway, um, implant can be in place for three years. The copper coil can be five or 10 depending on the one that you get. The next one along is called the I U S or the hormonal coil. And Marina is a kind of typical brand name that people might have heard of. Um, hormonal coils contain progesterone, so similar woman's in the implant. Um, and they can be in place for other five sort of 65 or three years depending on the brand and the level of hormone that you get. Um and they may either stop periods or make them lighter a much more sort of infrequent. So they can also be useful for managing heavy periods and heavy menstrual breathing. Um Next, as long as the injection, which again is the type of progesterone and it very commonly will cause women's periods to kind of stop or become very infrequent. Um And a woman would need to attend, they see every three months to get that injection, there's a little bit of leeway, but that's kind of roughly. So we still need to remember to kind of go to a kind of clinic or G P to kind of do that. Um The last and along on the top is sterilization, um you don't see this done a huge amount to be honest. Um because obviously, it's kind of unlike for men having a vasectomy, which is considered sometimes reversible. Um sterilization is considered definitely not reversible. So, um it would have to be a woman who is kind of very, very sure that she doesn't want Children, has completed her family. Um And it's done as a sort of operation by gynecologist. So, um we don't see that a huge amount, but it is kind of an option. Um And then going down along the bottom, um these are all options that you would need to kind of be regularly sort of using in order to be effective. So, um the combined pill is what people tend to mean when they say the pill, that's the one obviously people have heard of and it contains an estrogen and progesterone. Um The patch and the ring are basically similar sort of versions of it. Um The pill you would take sort of usually you take every day for three weeks, then you have one week off and then that's when you have a bleed. Um the patch, you basically use once a week and then have that week off in the same way. And then the ring you leave in for three weeks and then you take it out for a week. So all of them work by that sort of three weeks of having and then one week off, um it is safe and considered, you know, safe. Nowadays, from all the evidence, you can actually use these methods kind of back to back to basically just take them continuously, not have that week long break. Um, women may want to do that if they want to sort of not have as many periods or, you know, skip on if they're going away on holidays, something like that. Um, most people will find if you do that for several months in a row, you might start to get some spotting or breakthrough bleeding. Um All of these estrogen containing methods have got a few sort of, I guess additional risks that come with them. They're very small risks, but a slight increased risk of breast cancer and a slight increased risk of blood clots. Um There's some new evidence that's come out in the last few months that suggests now, actually some of the progesterone only method may also have that slight increased with breast cancer, but that's not yet. So kind of well established. Um And then there's also sort of certain rules with the combined methods to do with that increased uh increased clot risk to do with people's BP, weight and B M I and to do a people's age and smoking status as well. So it involves a little bit more of a kind of detailed kind of history and going through it. Um The UK MEC, so U K M E C um produces basically all of the guidelines on contraception and whether they are sort of safe methods, you know, not safe methods for all these different criteria and all different sort of medical conditions. So that's a good place to go and look if you just type in you kmex summary, all of that will kind of come up. Um And then we've got the progesterone only pill which contains only progesterone. Um and that would be a pill that you kind of take every single day. Um It's got less kind of factors to do with people with medical history, most women are eligible to take it. Um And with that, either your periods will kind of stop, they might say frequent regular kind of monthly or they might be very infrequent leading. Um And then lastly the sort of second side of that bottom bit. Um There's obviously male condoms that can be used. Um You need to use it every time you have sex and obviously there's risk of things like condoms, fitting and tearing. Um There are internal condoms or female condoms. Um You don't see these huge amount. Um some sexual health clinics will have them, but they can be a bit federally. I'm not sure. I don't think I've ever come across the patient who uses them regularly, but it is an option. Um And then diaphragm. So that's a sort of small plastic or rubber kind of device that the woman has to pop inside and placed over the cervix. It's basically another barrier method that's trying to create a barrier to the phone going through. Um You may use these alongside spermicide to try and increase their effectiveness. Um Again, you don't see these as much anymore. They kind of need to be fitted, need to get the correct size. I think some sexual health clinics do it again, I've not come across any patient's recently actually using these. Um and then the last thing is kind of fertility awareness kind of method. So um lots kind of goes into this. I think people used to do it years ago, it would involve kind of plotting your cycle involved having quite regular periods. You can actually kind of plot it out, often involve other input like kind of taking your temperature and things. And what you're trying to do is work out when you're fertile days and not fertile are um in really simple terms, um you're going to be fertile around the time that you ovulate because um any sperm that's released can hang around for about five days. So if you're having sex in the run up to that ovulation, the sperm might still be hanging around, you might still be able to get pregnant and then once you've ovulated, the egg will be around for a little bit kind of waiting for any sperm. So there's probably give or take that at least a good week in the middle of the cycle where you're going to be fertile. Um There are now lots of apps and things that people use to do this. Um I think, you know, I would say, and I think most of the apps have this in there kind of terms and conditions if getting pregnant would be something that you really don't want, a woman doesn't want would be kind of, you know, disastrous or really undesirable. Probably you should be using another method as a back up or, you know, not just relying on these because I think there's quite a lot of room for user error. It's not an exact science, you know, lots of stuff can affect people's temperature other things. So, and that's those. Um, and then just to say, obviously for a sort of sexually transmitted infections, so any sort of disease, disease infections, um you'll only be able to kind of prevent or sort of reduce transmission of those by using condoms. So, um, contraception will only stop getting pregnant, it won't stop you getting infections. Um, yes, we'll move on fine. And so, yes, the other bit to consider, obviously anyone that's had unprotected sex. Um, you need to think about ST I testing for testing for infections. Um, generally considered here from the point in which you have sex testing for gonorrhea and chlamydia, which is a kind of common bacterial infections that are tested in a routine screen. Um, it will take up to two weeks for results to show up. So if someone has sex, you may need to get them back in two weeks time or, you know, get them to go to a sexual health clinic to then do the swab in terms of doing blood tests. Um, usually routine screen in the UK would involve blood tests for HIV and syphilis if someone seemed to be at particularly higher risk. So, um, if they, you know, had sex with someone who is known to sort of inject drugs, um, involved at all in sex work, um, if, yeah, just things kind of like that. Um, you may be testing for hepatitis B and C as well. Um And then the other thing to consider is if someone has had sex in a very high risk situations, again, kind of drug use sex workers or if someone has been a victim of kind of sexual assault, you may be considering giving them pep which is post exposure, prophylaxis. Um That's basically medicine to kind of try and stop someone, um, stop someone contracting HIV from a kind of a risk basically. Um, we don't have time to go into that into detail. It's a bit whole kind of other topic. But yeah, just to be aware of those kind of things and fine and then if the scenario changes. So if the patient is under 16, um, does anyone know, uh, I think because it's only made a poll. So does anyone know what the age of consent is in the UK? Um And does the fact that this patient is under 16, does that affect your ability to treat them to sort of, um, discuss this kind of with them. Um, so I'll leave the pole, I guess for a few seconds. Just see if anyone wants to answer with that. Oh, okay. We've got a couple of responses. Um, please do keep responding. Um, doesn't matter if you get the answer wrong. Um, but I'll go forward to go through it. So the age of consent in the UK and this is for males and females regardless of the type of sex that you're having, um, is 16. Um, any sort of sexual contact, obviously without consent is illegal regardless of age. Um, and Children under the age of 13 are not considered able to consent to any type of sexual kind of activity. If, if someone is age 30 15 to 15, this is where in the law, it becomes sort of slightly more of a kind of gray area because technically any sex under the age of 16 is illegal. Um, but that law is kind of there to protect Children because, you know, we understand that there's a whole range of how kind of, you know, mature and understanding and, you know, vulnerable people are when they're kind of that age. So, um, you know, it's very unlikely, um, when you're kind of trying to assess this and trying to work out, you know, is it's safe, is this ok? Um, you want to think about the relative ages of the people in the relationship you want to think about if there's any concerns about kind of coercion. If there's any concerns about the young person that you're seeing, maybe not fully understanding or not be able to kind of, you know, consensus acts kind of with a, you know, full understanding around it. Um If you're not sure, um anywhere you're working, whether it's G P sexual health a any, um there should be someone that's responsible for safeguarding. Um and they would be a good person to kind of discuss with it. Um, in the cases of any sort of situations where there is concern. So for example, um, say you might have a 15 year old girl and you find that she's having sex with a much older man. Um, there's concerns maybe that there's some coercion involved that would be something where social services kind of would need to be involved. And so that's kind of huge refer to, um, if the situation was that, you know, you see someone who's 15 and she's having sex with her boyfriend who's also 15, they met at school, you know, parents are aware about, it doesn't sound that there's anything concerning that's absolutely fine and we'll come onto what you kind of use in a second when you're looking at, um, you know, prescribing contraception and kind of doing that, but police are not ever going to kind of want to pursue those kinds of cases. Um, the laws are there to kind of protect Children, protect people that are vulnerable and they're not there to protect under sixteens that are having kind of mutually consenting, you know, sexual activity in a safe sort of situation. Um So it can be a bit confusing because it is a little bit of a gray area, but essentially it involves a bit of kind of professional judgment, just kind of assessing the situation. And if you're not sure, you know, it's always just something to discuss with someone, you know, someone's senior, someone who knows a bit about safeguarding. And, you know, you can always sort of even discuss anonymously with social services if you want to get a view, if you're kind of not sure about it. Um So in terms of the kind of question, um there's two kind of aspects of UK law that come up with regards to um discussing contraception, prescribing contraception and generally consent of those who are under 16. So the terms that you might see, so there's what's called Gillick competence and then what's called fraser guidelines. Um They're two slightly separate things they do sometimes get kind of used interchangeably. Um but basically give it competence um that describes the ability in, in law of under 16 to consent to kind of medical treatment. Um And so this can be any medical treatment. So this doesn't have to just be related to sexual health of contraception. Um So essentially in the same way with adults, when you're, you know, discussing kind of capacity and whether people have got the ability to sort of understand, retain information about treatment way up and make a sort of decision. That's basically what Gillick competence is. So, you know, this recognizes that under sixteens are going to be really, you know, depending on people's age, depending on people's kind of education levels. There's going to be real differences in, um, you know, what Children or young people can understand. So with under sixteens and there's, there's no lower age limit for this, but, you know, usually is going to apply more to kind of teenagers. As long as the teenager you're seeing has understanding of what the treatment is. You know, they understand the reasons for it. They can understand the risks and benefits as you explain it, they can understand and look at kind of other options as long as you're happy that all of that applies, you don't need parental consent to them, treat that young person or that child. Um Obviously, you need to be kind of thinking that there's no undue pressure, no undue influence or anything. Um And it depends a little bit as well um with as with capacity with adults, you know, using Gillick competence that needs to be specific to every decision or every treatment that you're discussing. So something quite I suppose to relatively simple, like discussing if you're discussing contraception, something like that, but say there was a child, you had a very complicated medical condition and you were discussing a particular operation, it may be that their understanding is not kind of enough to meet the threshold for that sort of decision. And then in that situation, then their parents might, you know, be more involved. Um, obviously this doesn't mean that, you know, Children and young people under that age have to see doctors on their own. Of course, if they want to bring their parents, parents, absolutely kind of can be involved. Um, and if any, you're in any situation where you sort of are seeing, say a young person on their own, if you don't feel that they kind of meet that threshold of understanding around a decision that's been made, it would then be the case that you need to involve their parents to kind of proceed with any treatment that's get competent. Um, the slightly more specific bit in it, which is called Fraser guideline supplies just to kind of contraception. Um, and there's a few kind of extra bits to it. So essentially, um, it's the same in that you need to assess the confidence, assess your understanding. Um, basically going forward, you need to think that this young person is probably going to go on having sex whether or not we give contraception or not. So obviously, it's in their best interest to kind of have contraception. Um, and yes, you're looking at kind of best interests, um, there's going to be some kind of harm to them either to the physical or mental health if we don't, you know, give the advice to give the treatment and, you know, calm quite a strong word. But I think we could consider that to be, you know, catching an infection, becoming pregnant, getting their partner pregnant, you know, all of those things. Um, and while you would try with any young sort of people or sort of teenagers, while you would, you know, try everything you can to see that they, you know, suggest that they speak to their parents about it, suggest that they inform their parents and carers um if they cannot be persuaded to, but you feel that, you know, they understand everything and that's all fine. You can go ahead and you can prescribe contraception. Um If there's any questions, obviously kind of pop them in. Um And so yeah, if with the same 15 year old, if you say gone through the consultation, you prescribe contraception, that's all happy. If that patient's mother then called up the surgery and says, I know that my teenagers had a discussion with the doctor yesterday. I want to know all it's about what would you do in that situation? I guess it's having to think about confidentiality and how that applies to kind of teenagers. So, in that case, um there's all healthcare professionals, we've got a duty of confidentiality to all patient's and that includes under 16. Um It's really important to sort of reassure, you know, young people of this in appointments with a few kind of caveats. So in general, um anything that a young person shares with you will be kept confidential, unless you're concerned, there's a serious risk to them, there's a serious risk to another person. Um And then, you know, there's sort of basically those, those kind of situations you would break confidentiality in. So an example of that would be if you say had seen a 15 year old girl, and you found out that she was in a kind of concerning founding relationship with a much older adult. Um you were concerned that there was kind of coercion involved in that situation because there's kind of risk to her. Um there's risk of kind of ongoing harm, you would be able to break confidentiality and that would be kind of involving maybe parents and carers and potentially social services if you need to. Um it's really important if you are going to break confidentiality, the best practice is to inform the patient before you do so unless it's going to be putting them kind of in danger. So in, for example, in some kind of domestic violence situations, it may be the case if you feel that um a patient is very likely to kind of go and tell a partner or something, you may need to break confidentiality to put safeguards in place without informing them. But usually you sort of should do um in UK law doctors don't actually have a duty to report crimes. With the exception of anything related to terrorism. Um female genital mutilation F G M is another kind of exception. But if you did think you had information, um a serious harm is going to happen to someone, whether it's your patient with someone else, you may then get in trouble if you don't kind of just goes up to police. Um But you know, another example of this would be say you knew that you had a patient who was kind of smoking cannabis, for example, which is illegal, you don't have a duty to report them to the police unless um it was a situation where they were sort of a severe harm as a result. So yeah, we don't basically need to go and report kind of kind of police other than terrorism F G M and then obviously safeguarding situations for kind of Children, you know, social services would sometimes be involved. Um Yeah, we'll go into the next bit fine. So next case, um so 25 year old patient comes to the GP and she's got positive pregnancy test and would like to have got options for terminations. So um have I think, do you know what the law in the UK is around terminations around abortion? Do you know what the options are that are available and you know how she might access them? So the law in the UK that applies is the 1967 Abortion Act. I'm sorry, this is a very kind of busy slide, but it basically, I've highlighted the kind of bits involved um probably the most relevant. So um abortion in the UK is legal in certain circumstances. So it has to be performed by a registered medical practitioner, a doctor. Although nowadays, with the way a lot of clinics work, as long as there's a doctor that kind of supervise, supervising the overall process, a lot of the kind of appointments of patient phone calls of patient's may well involve other practitioners like nurses as well. Um Any abortion that happens needs to be authorized by two doctors. Um and that basically means to doctors will kind of, you know, be aware of the kind of circumstances will sign and sort of certified that they're happy that this case has kind of met the correct circumstances again in practice. Um Nowadays, it often won't be the case that those two doctors would actually see the patient. It may be more discussion's within their wider team and they'll be happy to kind of sign those forms based on the information given to them by nurses or whoever has seen the patient. Um Most terminations in the UK will take place before the 24th week of pregnancy. A very small number would take place after and that would only be in situations where there is really serious, you know, risk of grave harm of sort of, you know, serious harm to the women, um, or sort of death of the women. Um, or if there is a very serious kind of physical or mental abnormalities of the trials that have been born to be very seriously handicapped. Um, for the rest, the ones that kind of happened before 24 weeks, basically, they've got to kind of satisfy, um, at least kind of one of these conditions. And, um, essentially these are that the continuing of the pregnancy would involve risk, greater minister pregnancy were terminated. Um And that risk can be to the women in terms of her physical health or mental health or indeed to any other Children in her family. Um or that the the sort of pregnancy is likely to call grave injury to the women. Um All that the pregnancy is like these two cause kind of risk to the life of the women. Um Nowadays, it can be argued that based on all the kind of data and evidence um carrying forward a pregnancy is always going to cause more risk to a woman than not carrying it forward just because um your risk of kind of mortality and you know, morbidity from any pregnancy is greater than if you're kind of not pregnant. Um And studies have also shown as well that there are not considered to be any sort of, you know, ongoing adverse effects related to having a terminations, people's mental health. Whereas, um you know, in the case is carrying on pregnancy, there are increased risk of things like postnatal depression, you know, issues like that. That's not to say that having a terminations is, you know, for some people, obviously it will be a upsetting or kind of traumatic experience. But the overall data sort of shows that, you know, in general terminations are safe, you know, they're acceptable, they're kind of, you know, that's, it should be an option that's available to women and it's up to them whether they want to go through with that or not. So generally speaking, um it would be very rare that, you know, in most cases, if a woman wants to have a terminations, if she feels there's reasons to happen, you know, if it's before the sort of 24 weeks, she usually will be able to kind of have one. Um There's another section of it that sort of says doctors may wish to consider women's kind of social circumstances. Obviously, it can be a bit difficult. Um You know, because in some cases, women may want to have a termination if they feel they can't afford to have the child, if it's gonna cause impacts for their family, I suppose they sort of say that social circumstances may be taken into consideration. There's obviously an interplay with that and women's kind of ongoing physical and mental health. So it kind of all links together. Um The other thing to say, abortions in the UK for a sec selection. So aborting, you know, fetus based on the sexy that you're aware of that is not legal in any circumstances. Um It's not meant to happen very much. I think most the data says it's not something that does happen much in the UK. Um But if any sort of person assessing someone for terminations felt that that was a factor, um, they would have to refer to a sort of social services safeguarding and the terminations wouldn't be able to take place in that situation. Um There is a sort of aspect of the UK law that says that doctors can conscientiously object. Um There's sometimes not the best understanding of what this actually means. Um There was a case actually in 2014 in Glasgow, um where to catholic midwives working in a hospital, brought this case against the hospital and these were not midwives who are taking part in any, you know, terminations. They weren't involved in seeing the women assisting in the procedure. Um They were just kind of taking phone calls um because they were working on a labor award when, you know, awards where terminations took place, they were just taking phone calls, they argued they should be able to not be involved in that process. Um The court actually upheld that that wasn't, that wasn't what the law meant. So, you know, obviously, if they felt that that part of their job, they didn't want to be involved in, they would need to just find a job that else where they weren't allowed to object to that administrative kind of part of it. So the conscientious objection is basically just applied to kind of doctors obviously can choose and nurses not to be involved in the actual kind of procedure of a terminations. So, you know, involved in it, assisting in it. Um You know, I think it used to be the case that I think some gps, if they didn't want to sort of refer women determination, they would maybe get their colleagues involved. But I would argue based on that case, that would be a more sort of administrative bit and the law is very clear, if you do not want to be involved, you have to find, you know, the women another kind of option basically. Um Nowadays, I mean, in terms of women accessing terminations, you know, mostly shouldn't kind of matter with that anyway. Um you can be referred by your G P, you can be referred to sexual health and, but actually a lot of what's on nowadays is kind of self referral. So it depends a bit which area in um there's various organizations to be passed. Um Marry Stopes. Um And then New Pass is another one. They're all kind of charitable, but they are considered, they work within the NHS and it's all considered an NHS kind of service. So women will not need to pay for sort of any aspects of terminations or daycare involved, um, women can self refer. Um And actually during COVID, um there was a kind of roll out of um, remote consulting for this. Um and that's been sort of carried on, it's been considered to be safe and very effective and allows people to kind of have some of those early appointments and without any interruption to kind of work and other things. Um in terms of what actually the options are, there's basically what's called medical terminations. And that's kind of having uh appeal, appeals basically. And then there's also surgical's of terminations. Um You probably don't need to know huge amounts about the kind of details of it, but essentially for the pills, um you're given one medicine myth oppressed own which kind of blocks progesterone, which sort of stops the lining of the uterus continuing to kind of build up, which is needed for normal pregnancy. And then you're given a second medication, usually sit for a few days later, um called Misoprostal and it just causes the wound contraction. So essentially, um kind of causes cramping causes bleeding, but basically sort of causes a miscarriage to start happening. Um Those can be used up to 10 weeks and since COVID that can be done at home and it's considered perfectly safe to be done there. And obviously any woman will then have the support of like, you know, a phone line, they can always call up for advice. Um If it's from 10 to 24 weeks onwards. Um You would take the first pill at home, but then you'd have to come into a clinic or hospital to take the second tablet. And that's just because the bleeding obviously can be a bit heavier. Obviously, if you're getting more towards 24 weeks, um it's more like a process of going of going through labour, whereas earlier on it would be more just like having a kind of heavy periods or heavy bleeds. Um Surgical options are also available and you know, it will be assessed by whoever speaks to the woman, which option is going to going to be best. Um, vacuum sort of evacuation can be done, vacuum aspiration, sorry can be done up to 14 weeks and it can be done under local anesthetic. So, you know, done as a day case. Um and then delectation and evacuation can be done since that of 14 to up to 24 weeks. Um Depending on how late in, depending on other circumstances, women may be under general anesthetic for this where they may be under kind of conscious sedation like you're using dental procedures. Fine. We'll move on to the next case. Um I think the first two are kind of a bit longer. So these ones I think will be slightly quicker. So a 25 year old present to your clinic with abnormal genital discharge. And so this is kind of thinking about the sexual history thinking about the infections. Um, what kind of things would you cover? Um, and then as well, we've kind of mentioned some of them earlier but thinking about what are the common, um, sexually transmitted infections. Um, if anyone can think of any, um, just pop them in the chat. I think I've mentioned a couple of them earlier. But yeah, just pop anything you can think of it. So, um, going through sexual history, um there's some bits that are sort of specific to the sexual history part. And then as you see on the side, there's kind of other aspects that are very similar to when you're doing any sort of medical history or clerking. Um So this person's come in with discharge. So we want to ask, you know, what color is the discharge? Does it have a smell? Does it have any sort of itch or associated symptoms with it? Um Obviously in most cases will be doing testing? Um But you know, certain conditions will have certain kind of typical appearances or smells or kind of itch or not each, depending, you know, on the discharge. So in some cases, you may get a bit of an idea based on what the patient saying, but we will normally do me doing swabs or something. Anyway, um we also want to ask about any sort of urinary symptoms. So both men and women that would be if there's any kind of burning, passing urine if you go more often if you're having kind of rushed the loo, um, anything like that. Um We'd also ask about any sort of skin changes because there are sort of sexual, sexually transmitted infections like herpes, for example, that can cause kind of ulcers or blisters. Um, there are other things, you know, people will often come to sexual health clinics with different rashes on the genitals and often more often than not, these aren't actually other things actually transmitted. You know, it can be things like asthma, you know, things like that, but we would ask about it. Um And then we'd also want to know about any sort of systemic symptoms. So, fever, abdominal pain, vomiting because people can come quite unwell with kind of sexually transmitted infections. So for women, um you know, pelvic inflammatory disease and this is sort of information within the kind of absent and pelvis can be caused by some of the common infections. And for men, um epididymal or quite a so kind of infection and inflammation of I'd um testes and the associated kind of vessels again can be caused by common infections. Um, a couple more specific questions for men, you'd always want to ask about testicles, whether there's pain swelling. Have they noticed any lumps, lumps more for kind of testicular cancer rather than infections? But you, you know, want to ask about it. Um Do the test is feel hot red, inflamed, that kind of thing? Um For women, you'd also want to ask about bleeding. So, infections can sometimes cause um, postcoital bleeding after sex. Um and or infections can cause intermenstrual bleeding between people's periods. Um And then you'd want to ask as well about abdominal pain and then dyspareunia is kind of pain during having sex. So, pain during having sex, um would sometimes be something you'd see with pelvic inflammatory disease. Um just due to this sort of information kind of within the pelvis. Um And then anyone having anal sex, this can obviously be men or women. Um, you'd want to ask, you know, if they are having anal sex, are they having any symptoms there? So, are they having any rectal pain, any bleeding, any discharge and then what you would then go through? Um And this is in terms of when we spoke earlier about the kind of time frame protesting, you'd want to know about people's kind of recent sexual partners. So normally you'd ask about the last person they sat with essentially the person before that and then you know, any other people or how many others in the, in the past kind of 3 to 6 months. Um It's important to know what kind of sex people are having. Um, you know, just in terms of where you're going to be doing swabs from. So, you know, for women, it maybe vaginal swabs, you may be doing rectal swabs and oral swabs as well. And for men, you either will be doing urine samples, you may be doing sort of rectal swabs. Um, and then obviously for women, and we're considering as we've talked about before, any sort of unprotected sex and whether there's a pregnancy risk to do with that and whether you need to deal with that as well. And we want to know about past medical history. We want about drug history, contraception, any allergies, obviously, because it can affect the medicines that we can give. And then we'd want to ask about social history. So, um, we'd want to know obviously more relevant for young people, but kind of two people are living with any sort of substance use. You know, is there any concern about alcohol or drug use? You know, when they're having sex? Um, and lots of sexual health clinics now will routinely ask about, you know, do people feel safe with their partners? The only risk about domestic violence? Because often you can, you know, you may want to kind of give input there as well. Um I can see your questions going up. Are you required to break confidentiality to when former patient's partner if they're diagnosed and treated for an FBI? Um, so I think I will come onto this actually, I think it comes up in a second. Um But yeah, I will answer that question. Um, so fine. So we've sort of gone through the history. Um, and then how would we examine the patient and then what test would we think about doing? Um So for a male examination, we would, if, you know, presuming this patient got discharge, which is what we said in the case, we would want to examine the penis. If there's any discharge at the sort of actual kind of meatus of the penis would want to take a swab from that. We'd want to examine the testicles. We'd want to examine the inguinal kind of lymph nodes to see if there's any information there. We want to examine the skin. Um For women, we would want to examine the internal, external genitalia. The vulvar, look at the skin and again, feel the lymph nodes. Um if we're concerned about features of pelvic inflammatory disease, so concerned with kind of pelvic pain, if there's any, you know, fever and pain during having sex, um or if we were concerned about possible ectopic pregnancy. So if someone was pregnant and we're having kind of abdominal pains, they were unwell, those kind of things, we may wish to do it by manual exam, which is, you know, an exam with the fingers inside and what you're trying to see if there's any kind of pain on kind of moving the cervix. And if you can feel any pain when you're feeling up to either of the adnexa, kind of on either sides. Um Normally for women, if you're doing a full set of swabs, we would do a speculum exam and that so that we can do a set of swabs internally, including from the vaginal wall, from inside sort of, you know, entrance to the cervix and from kind of under the cervix as well. And then you may also wish to do an abdominal exam if you're concerned about sort of pregnancy related things or P I D. Um, anyone who's having anal sex and having symptoms, you would usually do an external exam because sometimes things like bleeding can be caused by other things like, you know, piles of hemorrhoids. If someone is having a lot of discharge, you would usually use something called a proctoscope. Um It's a bit like a speculum almost, but it's designed in a different way. So it kind of can be used going up into the anus, into the rectum and then you can do swabs that way as well depending on where you're working. Um there'll be different set of abilities of different things. So most gun clinics um will have the ability to do same day microscopy. So they will, you can literally take a swab, whether it's from discharge from the penis or discharge from kind of inside the cervix. You can literally and then whoever kind of does it looks at the slides kind of under a microscope and they will be able to sort of see if there's sort of different infections kind of based on that. Um for the kind of main infections we would test for So like chlamydia, gonorrhea, in some cases, trichomonas, um you would usually do swabs and they're called kind of nuts. Um, and basically what they are as the DNA swabs, they're looking for the D N A of those kind of infections. Um, depending on where you are, it may take, you may get the results back very quickly if that process in house, often some sense from G P it can take up to a week, it can take a bit longer. Um, you maybe wanting to dip the urine, obviously, some urinary symptoms, you know, uti S could cause some of the things you're an HCG. So for women, you want to check a pregnancy test and then you may also be doing blood test as part of a routine screens. So for things like HIV and kind of syphilis, um, so common sort of we've gone through that. Okay. Yeah, we'll go through kind of possible causes. I'm really sorry. I think this slide probably doesn't show up as well. Um, but I can't even read in, uh I think I can just about read it. So common stuff that will cause discharge in women. Um, there's kind of sexually related causes and non sexually rated causes. So, Candida or thrush or yeast infection is probably one of the most common causes of discharge in women and it's not actually transmitted. Um, it would typically cause a kind of white campy sometimes described like cottage cheese discharge can often come along with, it can often come along with some redness and things of the skin. And you would normally treat that using antifungals. So either kind of fluconazole as a sort of one off tablet or clotrimazole as a pessary that you put inside the vagina. Often in combination with the clotrimazole cream to use for kind of a weak men can get thrush, it's kind of less common really. And we don't really consider that women and men could kind of pass rush to each other, not usually. Um but for men, you would usually treat in a similar way with kind of either an oral tablet or just a queen. Um For women, I think the next thing down is, yeah, there's bacterial vaginosis. So bacterial vaginosis again is not a sexually transmitted infection, but it can be kind of caused by having sex. Um what it is really is we've, you know, women have all got kind of normal bacteria that sits within the vagina. It's what keeps it clean, it's what keeps it healthy. Anything that disturbs the balance of that bacteria which can be having sex can be washing, can be dosing can be different things. A certain type of the bacteria kind of proliferate. Um and the good bacteria, the lactobacillus, either consulate less of them. Usually people would describe sort of usually a kind of clear or white is discharge sometimes with the kind of fishy smell. Sometimes a lot more of it. Um, and that would normally, yeah. So the Russian be, be, would both be diagnosed either with microscopy or sending off a sort of empty nest walk to the lab and be, be, you would normally treat with metroNIDAZOLE. It's an antibiotics for sort of, for five days. Um, trichomonas is a sort of sexually transmitted infection. I've never heard of it until I actually did, um, did a gun job. Um, It's a sort of, it's a kind of flag elated organism. Um that kind of swims around, it's invisible to the naked eye, but kind of swims around in the genital track. Um It can sometimes cause a kind of yellowy discharge. It can sometimes cause a very inflamed or strawberry red looking kind of cervix. It can sometimes cause kind of bleeding for women either after sex or in between the periods and that's also usually treated with metroNIDAZOLE. Um And then the most common sort of sexually transmitted infections would be comedia and gonorrhea. Um for men and women, these can present with discharge or they can present often actually with no symptoms at all. And both of them would be common causes of P I D in women or epididymal crisis in men. Um Comedia would usually be treated with a week of doctor cycling. Um There's different options depending on sort of local sensitivities and gonorrhea would normally be treated with cefTRIAXone given as a kind of um intramuscular injection. Um there have been, I think in the last few years there's been different, you know, outbreaks of sort of cefTRIAXone or drug resistant gonorrhea. Um, so normally gonorrhea samples will always be taken and sent off to check sensitivities that, you know, you're treating it with the right thing. Um, fine. Ok. And I think we've sort of, we've kind of got there with the question. So in terms of breaking confidentiality, um we would in the UK um you know, obviously any partner, any person that is seen would have actually transmitted infection. Normally in a sexual health clinic, they go through a process called kind of partner notification. Um And that would involve kind of going back in time. Um looking through the partners that people have had and there are processes by which either anonymously, the sexual health clinic can send text or inform those partners. Someone that you have stepped with has been tested positive for this. Please come and you know, see our to go to a sexual health clinic to get tested and get treated. Um or if the patient is happy to do that themselves, then they can, you know, they can tell their partners, um we cannot add doctors break confidentiality um with regards to um sort of common FPIES. So things like gonorrhea, kind of chlamydia, um while obviously, you know, they can cause harm, I guess in the sense that they can cause symptoms and they can cause things that help the confirmatory to these epididymo-orchitis. Um, they're very unlikely to cause death kind of in any patient. And so I think where it sits in the law is that the harm is not considered great enough for us to break confidentiality. Um, obviously you would really want to strongly kind of urge someone to, you know, tell their partner. Um, I have had situations in sexual health where I've seen, um, yeah, where I've seen a partner and they've been very, you know, maybe they've been having sex with someone else that's not, they're kind of husband or wife. Um, and all you can really do is continue to encourage them to tell them, we can't do anything else. We're not allowed to break confidentiality. Um, in, in that situation, um, with HIV, it's a slightly more sort of complicated situation. Um, we still are not a kind of allowed to kind of break confidentiality. We need to kind of strongly encourage people to sort of tell their partner or to whoever they've had sex with. However, um, if someone knowingly have HIV, and, you know, knowingly is having kind of unprotected sex. So, you know, sex without condoms, um, they're having sex with people that, you know, they know they have HIV, they don't, they have not told the person they're aware of HIV, transmitted there where there is the risk of this person. Um, they can be prosecuted kind of under the law. Um, normally the prosecution's can only take place kind of post the fact. So if actually transmission has occurred, um, you know, people can then be taken to court's. Um, it becomes a slightly sort of difficult situation. But yeah, we're still under the law not meant to break confidentiality in that sort of scenario. Um, I guess you could argue when we were speaking earlier. Um, you know, in terms of reporting kind of coins to the police, you know, if we're thinking that there are serious harm is kind of going to come to someone, but it's a bit of a great area. So I think if there was any situation, um, where, you know, you knew of someone and this was kind of happening, um, you probably want to involve your kind of safeguarding leads, you know, maybe want to speak to sort of social services, maybe get advice about it because I think, you know, you can't just go and phone up whoever it is and, you know, tell them about it, you know, breaking confidentiality for that person. Um, obviously if, you know, someone is going out and kind of, um, knowingly having unprotected sex, then, you know, it's a bit of a difficult situation. Um, if people with HIV, you're having kind of protective sex, they're under no obligation to tell their partners, you know, um, it's, you know, if they're sort of using condoms or they're kind of on their medication, undetectable, they don't have to, um, there's a long list of notifiable diseases in the UK. Yeah, long list. But none of these actually transmitted infections and HIV, none of those are kind of on there. So, um, these would be kind of conditions where if you find a case or you're kind of in some cases suspecting of a case you need to local, um, sort of inform the local kind of health protection and local public health kind of authorities, but sexual health and HIV, none of them are kind of on that list. Um Yeah, if there's any questions about any of that again, put it in the trap, I know it's a slightly slightly sort of contentious area. Um Last case, so a 16 year old patient who is a female kind of at birth comes to G P and would like to discuss transitioning. Um He uses he and him pronouns and has been living as a mail for the last two years and is keen to start with the hormone. So, um so gender dysphoria um and that is a term basically that describes, I guess what this patient is kind of feeling and it's a sense of kind of unease or discomfort or distress because of a mismatch in someone's biological sex, of biological sex assigned at birth and how they feel how they identify it kind of gender. Um There's been lots of changes um kind of over the years and how this has been kind of classified um So the D S M which is the big American kind of psychiatric sort of manual used to kind of classify this a gender identity disorder. Um Part of that was just to do with in America. I think, you know, with getting medical treatment and you know, insurance companies paying for things unless something is classified as a kind of medical condition, your insurance, there is unlikely to kind of cover it um that has been removed because it was felt that coordinate disorder was kind of stigmatizing. So I think the term dysphoria is kind of still not used. I think some groups of trans people will still feel that, you know, there's some stigma even in that term. But yeah, it's gender dysphoria is usually what people would kind of use nowadays. Um not everyone was gender dysphoria will want to transition. Um People may feel like this, you know, throughout their lives. People may let decide they feel like this kind of later in life. Um and not everyone will decide that they want to kind of act on this, I guess. Um I suppose for lots of people, the first thing is they kind of change how they present socially. So what's called like a social transition. So that might be changing the type of clothes they wear, it might be changing, you know, the hairstyle um changing how they ask people to refer to them. Um and it can involve, you know, changing you name at G P, your name with your Employers Bank's kind of that kind of thing. Some people that's, that's all they will do that kind of that they're happy to do that. Um, other people will want to take hormones, um, such that they sort of feel that, um, some of the aspects of they're kind of biological sex which caused them the kind of distress itch of comfort. And so, you know, that may be for someone who feels more female. Well, it may be things like having body hair, having a deeper voice and things like that for someone who was born male but feels more female. You know, they may feel that um they want, they want to develop breasts, you know, they want to kind of look more feminine, I guess. Um all of this is obviously, you know, very person specific and I think, you know, we consider gender night to be more of a spectrum than a kind of binary thing. But yeah, hormones, that's usually where they would come in. Um And then the kind of other stage of it would be sort of surgeries related to kind of gender. And so that can be genital surgeries, but it can also be other sort of forms of surgery. So, chest surgery, for example, whether that's having a mastectomy or having kind of breast augmentation. Um, it may also involve other forms of surgery that are deemed more cosmetic, like different sort of facial surgery, voice box surgery, kind of shaving meds and apple or things like that. Um, yeah, as I said, it can, you know, gender dysphoria can be something that's experienced at any age. Obviously, lots of Children, you know, you may have heard of the Tom Tom boys, things like that. You know, lots of Children will kind of show interest in toys or activities and things that are, you know, societally more for the opposite sex. That doesn't mean all of those Children will go on to feel kind of at odds with sort of biological sex that they were born with. Um, I guess the ones that have experienced dysphoria, it tends to be more of a kind of lasting and severe distress and often puberty is when, you know, things become most distressing because oftenly there's changes going on with bodies that will kind of, if you feel that you're kind of gender is the opposite, you know, will be kind of distressing for you. Um, so I can see the question has come up about prescribing kind of hormone therapy. Um, so I suppose there's lots of aspects to this and I don't know how much people have kind of seen in the news recently, but especially for kind of the young person services, there's been a lot of changes and we'll go kind of threw them. Um, but essentially, um, we and GP as it stands at the moment, would never get involved in any of the actual kind of prescription of hormones as a starting point, you know, obviously we don't do surgery kind of anyway. Um, and you know, someone would need to generally go to a specialist service to kind of be assessed for all these things. So from GPS, from sexual health and patient's can actually self refer. There are kind of specialist kind of gender services. Um and that's where people will be kind of assessed. Um Usually the assessment will take place over a certain period of time. It may involve, you know, a multidisciplinary teams that might involve kind of psychiatrists, psychologists, doctors, um you know, from a range of backgrounds including endocrinology, given the kind of hormones as well and essentially pediatrics from the kind of children's side. Um once someone has kind of been assessed and, you know, gender dysphoria has kind of, they've decided that's the kind of diagnosis and things going to move forward. Um The specialist clinics may start people on hormone therapy and they may refer people on to have certain surgeries. They may offer people kind of voice coaching and things like that um to change kind of deepness of the voice. Um And for kind of Children and young people are kind of precursor to the hormone therapy may involve what called puberty blockers, other medications to kind of try and halt the sort of process of puberty. Um often, um you know, during this sort of process they will look at whether a patient has kind of socially transitioned. So, you know, that's the things I mentioned earlier about whether people have, um you know, using a different name, using different pronouns and dressing differently, asking people to refer to them in a different way, kind of living in the opposite kind of gender. Um the way it sounds at the moment. So anyone that is 17 and over can be referred into adult services. Um There's nine of these in England um as it stands, the waiting lists are extremely, extremely long for these. So um the Tava Stock comportment is the clinic in London. Um The only one um I checked the website the other day. They've got 12,000 patient from the waiting list at the moment and currently they're seeing people for first appointments who referred in July 2018, which is I would say pretty shocking. Um I think, you know, we know the NHS is under huge months of stress kind of generally. But um you know, from a GP point of view, I would say for most other specialties, we consider it quite a long way if people are waiting, you know, 12 months, nine months to see a specialist. So, you know, this is, it's a really long wait for people. Um anyone who is 16 and under um it's specialist kind of child and young person's kind of services which are called gender identity development of services. Um there's been quite a lot of controversy around these. Um And there's a doctor called Dr Katz who has been kind of basically conducting a huge review. Um, that was actually published kind of last year. Um There was a court case in 2020 this case, well, versus Haverstock and essentially what was involved, it was a woman who she's now in her kind of twenties, she had gone through a sort of transition supervised by one of these kind of, you know, young people connect when she was back 16 and that had involved taking, I think first puberty blockers and then having hormone sort of testosterone, she wanted to transition um to sort of to mail. Um she later kind of down the line I think had regrets kind of with this decision. Um And as we're going to discuss them in, there can be some kind of longer lasting effects that come from taking testosterone. You know, there's some things that are not reversible. Her argument was that, um you know, maybe she wasn't able at this age to make that decision. Um And maybe the whole process needs to be kind of looked at. Um essentially, there was kind of, there was a judgment made at the time saying that um no one under the age of 18 should be able to consent to these treatments. Um The High Court then looked at it again and said that they actually know that was probably wrong that was overturned to 2021. Um uh If you look at the kind of data and kind of numbers and all of this, um it's a very, very, very small proportion of people that would end up in this situation, that kind of go through a transition and kind of later regret it. Um Obviously, the processes in these clinics, you know, it's a very kind of long process of assessment and everything else. But because of that, while this was kind of all going on, there's been a kind of pause on the way that these clinics kind of operate and run. Um So the Taber stock used to be the one that kind of covered London and then there's another one kind of up north in England. Um there's going to be a movement across to these clinics kind of being run more by sort of pediatrics kind of services. So having, you know, being set up more in kind of specialist pediatric hospitals, still having input from psychiatry, still having input from the kind of gender specialists that were running these initial kind of clinics. Um that whole process is kind of in flux at the moment. So um as it's done, you would still kind of make a referral to one of these kind of specialist younger people clinics. Um But I think it's going to be over the next few years, how that whole process is kind of operated is going to be sort of set out. Um what the cast review came up with as well is that there's actually still a real lack of research kind of in this area. And so because of that, you could argue that some of the treatments are kind of not as evidence based as we would hope them to be just because there isn't, you know, much evidence to go on. Um So I think, you know, Children still and, you know, Children, young people still in certain cases will be able to access hormones will be able to access puberty blockers. Um But it's going to be, you know, a very involved process and assessment for that. And it's certainly nothing in kind of primary care or anything that we would be involved with. It's all gonna be done by the specialist services. Um in simplistic terms, puberty blockers are basically to try and delay the onset of puberty such that you can stop some of the kind of irreversible changes like best development of hair growth that happened during puberty. Um These are kind of considered to be reversible usually. So if you then stop the puberty blockers, you know, most Children would then go on to go through puberty a later date. I guess the idea with it is kind of while you're deciding, deciding what's going to be the best thing, you can kind of hold off puberty kind of happening. Um Hormone therapy is to the slightly difference that's either giving estrogen or giving kind of testosterone type hormones. Um and the changes that come from that are considered not to be so reversible. So, if you develop breast as a result of estrogen, you know, those will stay and if you've always deepened from testosterone, those will stay and it can cause kind of infertility, um that may not be reversible, sort of either. So, um I guess that's a bit that, you know, takes a bit more consideration. Obviously, this whole process, you know, cams and kind of psychiatry will often be involved. There's a lot of kind of therapy and things that go on. Um That's not to say that everyone who wants to transition has mental health issues. It's just that we recognize it's a very complex area and, you know, Children and their families probably will need to be supported through it, adult patients' kind of as well. Um For admiral patient's, um they will you be referred to the gender clinics, these are still running kind of as usual. I think they're looking to set up more of them given this huge kind of waiting lists. Um often counseling and therapy, you know, people will be on these waiting lists for a very long time. So you may need to refer them to access kind of other forms of counseling and therapy, you know, if there's mental health kind of issues, um obviously you would manage any sort of mental health risk in the same way as anyone else. So, you know, if patient's of suicidal, which sometimes people can be as a result of the distress, you would still have to refer them to mental health services as you would with anyone else. Um, in terms of what's offered to adults, you know, once they go through this whole period of assessment, hormone therapy would involve kind of assessment by two sorts of different clinicians. Um And usually, you know, there, there doesn't seem to be a time frame on how long people have socially transitioned for that, but I think they would take it into account um if people are referred to go and have chest surgery. So for, um, you know, that would be either having kind of a mastectomy. Um People are sort of considered to need to be living as the opposite gender for around a year. Um And often you'd be sort of taking masculine zing hormone testosterone for at least six months before the referral. Um in terms of hysterectomy, um for sort of people born as women, um having testosterone for more than two years can actually cause kind of endometrial room lining thickening. And so either you need to be following this up with scans, which for some people might be kind of an upsetting thing to have as it kind of reminds them of the previous gender, um or what you can do as a hysterectomy. And again, usually the year of social transition for that in terms of genital surgery. Again, usually you're kind of social transition. Um There are some surgeries that are considered um kind of, you know, cosmetic things. So mastectomies would be funded. Um but having a breast augmentations, they're having kind of best impacts, putting is considered cosmetic things. So people may wish to go and have that done kind of privately. Um The other thing to say is that there are part probably to do with these really long waits. There are a number of private clinics both in the UK and abroad that do operate and do offer chronic hormones. Um These are quite variable in how they're regulated in terms of, you know, how safe and everything and stringent their procedures are. Um lots of patient's are getting hormones this way. So, you know, in an ideal world, if they're going to private clinic, it's at least run by kind of, you know, doctors or nurses who have training in this area and, you know, often they will be monitoring and doing things into the sensible way. Um In some cases, people are just getting hormones from less reputable, I guess clinics or just getting them online. Um N H S clinics can still do monitoring for this. So within London, um 50 60 which is operated out with 50 16 street Sexual Health Clinic in Soho and they offer a monitoring service. So the argument, I guess being that if people are going to be taking these medications IV, for getting them elsewhere, we should still be doing, monitoring them, you know, in order to do that sort of safely. Um, if people come, you know, asking this and G P often, it's something that we'd have to get advice on so we can do monitoring that. We'd often to get advice from a sort of gender clinic as to what protocol that we're kind of following. Um, GPS usually can be asked to prescribe hormones, but this is usually once um you know, someone's been established on them by recognized kind of gender clinic, there's a clear kind of shared care agreement in terms of, you know, monitoring what was needs to be done, how often troubleshooting and obviously, we can then get advice from gender clinics if we need to in terms of patient's that have been accessing hormones kind of online and then are asking their GPS to prescribe them. That's more of a kind of decision about risk and whether people are happy to do that. But in some situations, if you can get advice from agenda clinic, it may be something that GPS would be able to do um in terms of other legal aspects of it. So you can change your gender and title and most documents um without a sort of legal change of gender. So you can just ask your GP to change on the system, asking for us to change banks, the driving license um for a passport. Um it's different, you need to basically have a letter from a service. So usually people would have had to have gone to a gender service to get a letter from a consultant for that. Um Gender recognition certificates are a bit more complicated. So that allows people to then actually change the birth certificate, therefore, get married within the gender that they're kind of now living in. Um It involves quite a few things. Um It's apparently very arduous and difficult to kind of get because you need to have all this evidence that you've been living as agenda for a long time. You need multiple medical reports. Um And just, yeah, it's in practice, unless you've been seen and kind of assessed by gender clinic, most people are not gonna be able to get all this evidence together. So you will find a lot of people and lots of trans people won't have actually changed the birth certificate, but they may well change, you know, passport driving license, those kind of things. Um It does have implications for GP obviously, I for example, have got patient in my practice who is on hormones. Um you know, now identified with male, um but he's not actually had a hysterectomy or sort of genital surgery, so he still does have a cervix. He obviously in our system is an email, so he won't get kind of quoted or flash up for the kind of regular minders for cervical screening. Um So, yeah, once I kind of met him and I think the upper report, it was something I then discussed and obviously for people and you've experienced dysphoria, going to have something like a cervical screen can be something that's quite distressing. So it's important that, you know, they're aware and I think what I did was sort of speak to the nurse in our practice just as she was aware of the situation and he went on and had to kind of screening obviously, then he just, you know, we need to kind of remind them to do that every few years basically. Um Yeah, so that's everything I feel been talking to him for quite a long time. I think we have gone over an hour. So sorry about that. Um Are there any other questions or anything? So thank, thank you very much. I think that was very, that's covered a lot of very difficult topics within sexual health. And I hope that that's been made a bit clearer to the audience as well. Um I'm just about to send out a feedback form as well and if you wouldn't mind, please fill this out for Fiona. Yeah. No, that'd be great. Thank you. Um Yeah, if there are any questions at all, please pop them in the chat. I know there was kind of lots of stuff and I'm happy to happy to kind of answer anything. Maybe not fine. Yeah, I guess, I guess we can wrap up then. I think, I don't think there's any questions. Um, just, uh, okay. So what was one question? And thanks. Um, so for GPS, there's not once you kind of qualifying, do you G P exams? Um, lots of GPS will have kind of special interest in different things. Um They don't tend to be particularly formal kind of pathways or training program to actually do this. Um, I had a job at a sexual health clinic during my GP training. So I was there for six months and I did my F srh. So it's a sort of qualification in kind of contraception whilst I was there. Um And yeah, lots of people would choose to do that if they're kind of doing sexual health jobs. Um I really enjoyed it. So um when I was in my first year of being a G P health education in England Fund, a lot of kind of fellowships called spin. It's kind of to do a special interest and new to practice GPS. Um So I used kind of that money to basically go back to the sexual health clinic. Um working there a day a week, I did some sexual health, just kind of general clinics and then I did um further training and kind of cause and implants. Um And then thankfully happily, the sexual health clinic have kind of kept me on doing that half a day a week. So half a day I go there and do kind of cause and implants. Um So it kind of find your own opportunities really if it's something you're interested in. Um, it's often just a case of contacting, you know, contacting specialists, contacting things in your area and seeing this is any opportunities. Um But yeah, people are often very happy to have, you know, people come for learning or come to different things. Yeah, I guess bigger should be wrap up. Now. I think that's probably if there's no further questions, that's final, we'll just wrap up. Yeah. Yeah, please just complete the feedback phones. So thank you. Yeah, thanks. Thanks everyone for attending. Thank you for giving up some of your Saturday afternoon for it. But yeah, I hope you find it useful. Okay. Thank.