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Messages or anything. My name is Alex. Uh I'm an F one doctor and uh I'm here to talk to you a bit about uh sexual health uh in the context of LGBTQ plus healthcare. Uh So just, oh, that's, oh, that's loading. OK. Uh So just a little bit about what I'm gonna talk about. Uh I promise it's not gonna be too many slidess and you don't have to, I would like a bit of audience participation if you feel like it sends the messages, I'll be monitoring throughout. So, first of all, just cover a little bit about sexual health history taken uh specifically just a few notes and things to remember with regards of sexual health history, taking this particular situation. And then we're gonna move on to some advice on safe sex practices for LGBTQ plus patients. And then we're gonna talk about prep and OX and then we're gonna have some questions. Uh And yeah, as I mentioned, at the end, we're gonna have a slide of the future sessions that we're gonna do and uh QR code for some feedback. So, first of all, before we start, I would like to hear some of some of your thoughts on the chart about why is it important for us to talk about sexual health in LGBTQ plus patients? I'll give it a couple of minutes. It's ok. Uh, I'll, I'll talk a bit about why I think it's important and you can tell me if you have any thoughts as well. Well as we know, unfortunately, and as has been seen quite a lot of studies and systematic reviews throughout the world, not just in the UK LGBTQ plus sex education is very much lacking still in most of the world. Uh So we have an entire patient demographic who have received significantly less education in their schools or in whatever other context with regards to their own sexual health. Unfortunately, it's also a subject that is sometimes overlooked in medical schools with regards to how they teach us about. Uh for example, sex, safe sex options outside of vaginal penetrative sex and how exactly to guide our patients. And well, um I do have, I have a picture here of the Aids memorial quilt, which is I think is the first thing that we, I think it's something that we all think about the AIDS epidemic uh about why it's important to talk about sexual health. Um It is, there was a, it, it is an epidemic that's claimed the lives of millions of people worldwide. It's one that was unfortunately due to discrimination ignored by both politicians and unfortunately, healthcare systems alike. When it first started because of the population that it was affected, affecting, which was primarily, uh, men who have sex with men. And it still remains something that we need to be mindful of to these this day. Although we do know that most recent data on new HIV transmissions from 2021. Uh, if you're interested, there is very much uh, an article in gov.uk to talk about the trends in New HIV cases. We do know that nowadays in the UK, most, most newly diagnosed people who get a diagnosis of HIV are, in fact, people who identify sexu sexual and don't have, uh are not men who have sexual contact with men that is largely due to quite a lot of things have happened. Quite a lot of cautions from the LGBTQ plus community and protecting themselves and something that we need to remain mindful of uh as we go forward. Um There is very much, quite a lot to be said about the history of HIV and AIDS and the things that went wrong and the things that were done wrong by the medical community. But um although I could talk about this for quite a long time, I don't think that's the point of the session. So I think the point of the session is to just prepare you, give you a better idea of advice you can give to your patients going forward about how to remain safe in their sexual health. Uh So let's move on uh to taking a sexual health history. So I imagine a lot of, you know how to take a, a basic sexual health history. Uh It's, it, it can be an uncomfortable experience for both a clinician and a patient alike, but it is important if it's relevant. Um So the thing that I want to talk about more is taking an la sexual health history from LGBTQ plus patients. And very specifically, I wanna talk about the fact that we should always be mindful that are patients who are LGBTQ plus have had barriers in accessing healthcare in their life and may have had adverse experiences with healthcare staff in the past of discrimination, of ignorant behavior of anything like that. So it's always important for us to be mindful. It's always for always important for us to be as we always are empathetic to our patients, listen to them and talk to them about why it's important that we ask these questions and why we're asking them in this way. Uh some important aspects to remember in a thorough sexual health health history, which is important, for example, when taking history for starting preexposure prophylaxis or continuing prep. Uh I know this can be sometimes quite an uncomfortable conversation to have, but it is important. And I think if you are clear with your patients about why you're asking these questions and explain why you need to know that's quite important. But things to think about is type of sexual contact that our patients are, are having. So, is it oral sexual contact, vaginal sexual contact, anal sexual contact. But also it's important to ask if they're giving or receiving, especially when assessing risk, exposure behavior or behavior that puts the most at risk of receiving, uh, o of being diagnosed with. ST is, um, it's important to talk about the sex of their partners and the number of partners they've had. And if it seems appropriate and if you are worried, you need to screen for risky sexual behavior, uh such as chem sex, which is sexual contact, which is also done alongside illicit substances. There are quite a lot of re resources on this. I've not spent quite a lot of time on this, on this session because it would be quite a long time, but it is a risky behavior. There are quite a lot of resources that you can flag to your patients if they want to discuss this, if they can, if they wanna take safety measures about this because it sometimes is quite associated with addiction to illicit substances. It is also important to sign post to these patients if they are showing signs of dependence to illicit substances to the appropriate services for that who are able to help them. Uh And at the end, I'm gonna have some resources about things to read up on and also websites to kind of direct your patients to if they're seeking help. Uh Yeah, and yeah, keep sending me questions throughout, we can talk about them at the end. Uh And we're gonna move to prophylaxis and safe sex advice. Uh So I imagine we've, most of us have been taught about well advising condoms to our patients and also how to counsel someone on contraceptive pills and things like that. But I wanted to give some more additional specific advice that we might not be widely familiar with. That is important for our patients. Um So for first of all, to cover oral sex, just advice for patients would be to avoid oral sex if there are any cuts or sores present in the mouth or lips. And there is also a preventative barrier prophylaxis for oral sex, which is called a dental dam. It is a thin flexible sheet made of latex or other materials. It is also used in dentistry uh to prevent infection in the patient's mouth interestingly. Um And it can be used as prophylaxis during oral sex as a barrier to the genitalia to prevent any type of risk of transmission. Um There, there is also some guidance uh for patients in how to uh convert condoms into dental dams. But I've not really put that in there because I'm not, I'm not sure if whether or not the efficacy of the dental dam would be affected with that. Uh So, and I wasn't really able to find any studies with regards to this. So I would say just to advise for using the correct material, using up a dental do that's fit for purpose, it would be the best advice for patients. Um Secondly, to talk about digital penetration, it's important to talk to our patients about hand washing before and after sexual contact, uh trimmed fingernails to prevent micro scratches. And ideally, the recommendation would be if they're having sexual contact with multiple partners if they want to avoid the risk, the use of latex gloves. Uh And finally, I wanted to talk about the use of sex toys, which is if they're shared between partners, it's essential to clean between each platinum and before and after use. And also the recommendation would be to use condoms on these sex toys and a different condom for each partner. And just for, for a separate note, just some additional advice for trans and non-binary patients. So this specifically for I trans men or non binary patients who were assigned female at birth and are taking hormone treatment or trans women who have had gender affirming surgery and non-binary patients assigned male at birth who have had any type of sur uh any type of bottom surgery, which is that there is an increased risk of microscopic skin tears due to lack of lubrication. So it is very important for those specific patients to advise them to use an appropriate amount of water based lubricant. And as a blanket statement for patients with vagina's reminder that to inform them that taking hormone treatment does not reduce the risk of pregnancy. So they need to be aware of that. Uh, so in addition to this, I'd like to talk a bit about preexposure prophylaxis or prep. Uh, I know you've had a session on HIV last week. Uh, but, uh, I just wanted to talk a bit about in terms of patient followup, patient appointments, things that you need to make sure get done. Uh So yeah, medication is empty cyab with Tenofovir diap proxil 200 to 245 mg once daily. Uh So both of these constituent drugs can be used individually for the treatment or prophylaxis of HIV. Uh And I believe that 10 4 or disoproxil can be used on its own if there are significant contraindications to emtricitabine for a specific patient. Uh Some side effects, common side effects would be gastrointestinal symptoms and anemia. Initially, some things to be aware of is that patients who are taking this medication are at risk of neutropenia. So that's something to be aware of. And also, uh I've put in a bullet point here for viral hepatitis. So both of these medications are contraindicated for patients who have a history of Hepatitis B or C. Uh Currently, the advice on B NF is to administer with caution. Uh It is always very, very important to be aware of the pa whether or not the patient has Hepatitis B or C before starting prep. And also whether or not they're receiving any treatment for this because there's quite a lot of interactions and it can have, it can very much increase the risk of hepatic side effects from this medication. Yeah. Uh a little bit, a few notes about dosage and missed doses. So, dosage is once daily at the same time every day and the effective period starts seven days after initiation of prep. Uh with regards to make missed doses. Uh If it's within 12 hours of scheduled time, the dose can be taken at that time. If it's over 12 hours, then the dose is counted as missed. And you uh you would advise your patient to just take the next dose dose at the, at the, at the scheduled time. Uh You should inform your patients that at least six daily doses in the past week should have been taken for full protection. And if there's over one missed dose, they need to get in touch with the clinic. Uh and a bit of a discussion here about talking to your patients about this. Um It prep is one of the medications which adherence is very, very important. Uh So it's important to stress to your patients before they start this medication. That adherence is the most important thing. It needs to be taken every day. It needs to be taken around the same time every day. And missed doses are not something to be taken lightly. Uh There is also the availability of prep on demand, but that is only for anal sexual contact. Uh It's currently, I believe only recommended for men who have sex with men. So prep on demand essentially means that they are instructed to take two tablets to double dose 2 to 24 24 hour from 24 hours prior to sexual contact up until to two hours prior to sexual contact, they take another tablet 24 hours after that first dose and then another tablet 24 hours following the dose. Uh So this is, for example, if you're in a prep clinic and you're seeing a patient and they mention that they've missed some doses of their prep or even if you're in a GP anywhere. And this is an option that they need to be aware of because unfortunately, if they miss doses, then the protection from prep is significantly reduced. Uh And therefore, it's important to make them aware that there is another option. If they're having a hard time with the strict schedule of taking daily prep, they can switch to prep on demand if they are eligible. Um Just a quick note uh from reading the research from the British HIV Association. Uh What they've quoted is that there is not currently any research about the efficacy of prep on demand for trans patients. And therefore they advise not to prescribe prep on demand for trans patients. I unfortunately, I'm not, I'm not sure what that could mean. I'm not sure whether or not it is just, it is just a lack of research through which they, they're not able to advice at this time that trans patients take prevalent amount uh in their current guideline for prep. Uh I'm I have a link to their website later on because they are, they are the ones who produce quite a lot of guidelines and they're very, very thorough. So, moving on to initiating treatment. So first and foremost, prior to initiating treatment or recommending treatment to a patient who you may think is at high risk or a patient who may approach you and say, well, I think I am at high risk. Um First of all, as I said before, very, very important to educate people on adherence to prep. Um because unfortunately, if a patient is taking prep and they believe that they are protected from HIV, they might, for example, not get tested as regularly, that's not what we advise, but that might be the case. Uh and something might be missed. So it's important, very, very important to talk to them about pre adherence and also discuss safe sex practices as we spoke about. If relevant, I do think it's relevant if you feel like you have a rapport with your patient to talk to them about risky situations, risky sexual contact, explore with them why they're seeking to initiate prep, provide them with counseling about whether they're seeking to, to, to, to, to initiate prep prep, which they can, you, you should counsel your patients throughout the receiving prep if, if they are, if, if they're being seen in the context of a prep followup appointment in a sexual health clinic and prior to initiation of treatment, the recommendation is for baseline HIV testing. So that is in two parts, uh A combined antigen and antibody HIV test within four weeks prior to initiation of treatment and a blood based point of care test on the day. If the patient has had a high risk exposure to a possible sexual exposure, exposure to HIV in the past 72 hours, it is important to consider that they are not suitable for starting prep at that moment. And you might consider them starting them on post expo exposure, prophylaxis following sexual exposure. Uh I'm I, I've not spoken about post exposure prophylaxis in my slides. But uh if we've got time at the end, uh I can talk a bit about it. Uh but it, it's after postexposure prophylaxis for sexual exposure, they can transition into taking prep. Um There is a way to wean it. Uh but ii, if they've had this contact in the past 72 hours, they are most likely a candidate for pet as opposed to drug. And if they've had a high risk exposure in the last four weeks, you have to consider testing them for an HIV viral load alongside the combined antigen and antibody test within those four weeks prior to initiating prep. And additionally, you need to take a baseline renal function. Um There is the, the, it's not necessarily that prep does affect renal function as much, but it is important to have a baseline creatinine clearance, especially for patients under the age of 45. Um who don't have any other uh past renal history or any family history of renal problems. Uh And as I mentioned before, s ti screening is important specifically for hepatitis as that can affect whether or not the patient is suitable for prep and how we will give it as well as monitoring. So, a bit about monitoring uh after one month of initiation of prep, there needs to be an assessment that can be done over the phone as well. Uh So it's a discussion about how the patient is getting on with the prep if they're having any significant side effects that are affecting their life, uh discussion about adherence. Um I am going to mention that this a lot about prep adherence is very important, uh possibly HIV testing as well and asking them and discussing with them about symptoms of seroconversion that they might be having. And following this one month assessment, it would be a follow up every three months in a sexual health history i in a sex in a sexual health clinic. Uh So patients who are on prep are given 90 tablets at a time in the NHS. Uh and they attend three monthly appointments to receive the next dose of prep and also have uh the three monthly follow up of prep. So this is where discussing a complete sexual health health history becomes very important. So number of partners type of sexual contact, all of these things come in to a prep monitoring, follow up meeting. So it's quite a lot of information and uh unfortunately, it is quite uh it has to be a very, very frank appointment. Uh There's really, and there is a necessity to not be polite about the details, but it's always important to explain to our patients why we're asking these things. And it's very, very important to discuss adherence with them because this is the appointment where you might find out that the patient isn't, isn't coping with having to take the dose every day and they're not, they're missing doses. And this is very importantly, something that we shouldn't make our patients feel guilty about. But if they are missing doses, there needs to be a further discussion with the patient talking about what exactly is preventing them from adhering to their medication. Seeing if there are any ways that alongside them, we can figure out a way that they can make find solutions really such as setting an alarm on their phone, changing the time when they're taking it, anything like that to see if there's any for them or if it is appropriate and if it, we are talking about anal sexual contact and specifically men who have sex with men, it would be appropriate to also discuss. Um Sorry, I believe I got disconnected there for a second, but hopefully you can all still hear me. Uh It's also important to discuss whether or not this patient feels like they benefit more from on demand prep as opposed to uh taking regular prep. And alongside this, uh there is also HIV and sti screening at every follow up meeting. Uh I've also put in a slide for uh I've, I've put in a note for renal screening. So renal screening is not necessary every three months for most patients. Um But if our patient is under 45 years old and is shown to have a creatinine clearance less than 90 on their initial testing, then they might sorry less than 40 years old, then, then, then they might be eligible for annual screening of serum creatinine and egfr urinalysis. Um because they might uh additionally if they Yes, so that because it might be important for them to have this monitoring done uh in my personal experience in uh a sexual health clinic that I attended uh during my placements in medical school in medical school in Greenwich. They were also doing renal screening every three months. Uh I've looked into the nice guidelines. I'm not, unfortunately, there's not a lot of clarity about whether or not, they recommend renal screening. I would say that as most of the nice guidelines refer back to the British HIV Foundation Guidance. That is the thing to go on, but it might vary from clinic to clinic uh as you are uh usually already taking blood for HIV and S TI testing. Um and it is also important prior to initiation to discuss hepatitis B vaccination with all of our patients. Uh and another part of monitoring for HIV post prep. Uh while on prep is monitoring for any symptoms of cir conversion, any symptoms of HIV infection and also any side effects that might be adversely affecting patients lives because it is always a ri risk assessment whether or not prep is indicated that might change for our patients uh during their time with us. And just a quick note about stopping prep. So if our patient decides that they don't want to continue prep, for whatever reason, they decide they don't want to continue prep, they need to know what the stopping procedure needs to be. So for regular prep, it needs to be taken for seven days following the last sexual contact before they can stop. And for on demand prep, it is important that they take that 3rd 48 hours, 48 hour dose prior to stopping that on demand prep because that will give them the lowest risk. Sorry, I can't see my slides but ok, and finally, just a quick note about OX, which we used was previously known as monkeypox. So currently in the NHS website, uh patients who are men who have sex with men and have multiple partners or engage in groups, sexual activities are considered to be a high, higher risk and may be eligible for a vaccine uh with the NHS. Um uh As you may know, ox is transmitted by contact with infected blisters. Uh So that can be, it is, it can be also transmitted with sexual contact also with contact with soiled sheets and things like that. But that's most mostly for healthcare professionals. In terms of sexual health, it can be transmitted through sexual sexual contact because it of skin to skin contact with a patient who has a rash and blisters. Uh The symptoms are a rash with a blister like appearance which can appear usually the face hands or gen genitalia, but anywhere on the body, uh fever, muscle aches, general malaise headache, stiff joints. Um and the typical onset from infection is 5 to 21 days. So it's quite a long onset. Uh So if a patient comes and talks to you and believes that they may be at risk of ex that they may have been exposed to ox, it's important to try and get a full history of the last month of their life really and figure out when exactly this contact happened because it has quite a long in it can have quite a long intubation period. Uh There is a vaccination available. It's a combined smallpox and ox vaccination. Uh and it's taken in two doses, one initial dose and one take taken subsequently 28 days later. And just in regards to post exposure. So for patient comes and sees you in any medical context because they've had some type of exposure to ox. Uh vaccination can be given up to four days after exposure that can be extended up to 14 days for those who are either at high risk of infection or at high risk of having quite severe impro So that's young Children, older people, um immunocompromised people. And there is also the second vaccination do dose to be given 28 days later. Um Yes, ox is uh still ii believe it's, it's very much still around in the UK. We don't encounter it very often but it is something to be aware of. Um and to, to look into for our patients if they require it and if they require this vaccination. Mhm. And that's it. For me, I've quite, I've powered through these slides quite quickly. So uh please send me your questions. Let me know if you want me to talk a bit about postexposure prophylaxis. I thought that we wouldn't have time for it, but it seems that we do. Uh so we can talk about a bit a bit about who's at risk who's most at risk of uh needing post exposure prophylaxis if, if they come to you with a possible risky contact. Who do we consider to be someone who's eligible for post exposure for prophylaxis? Cause they have a higher risk of charting HIV. But, uh, I'm sure that you, you've probably covered quite a lot of it in your HIV talk yesterday, sorry, last week. Uh, so it might be that you've, you've had quite a lot of information about pep already. Um, yeah, let me know what your questions are. And if you wanna ask me anything, I'll um yeah, we'll let you have a think about some questions. Uh I thought I'd pop in with a question first then. So if we, when I'm communicating with a, a patient about like their sexual health history. Um yeah, maybe they're an LGBT patient. What, what do you think is like the main change or addition I should make to my practice to be respectful or inclusive? Like what, what's the main takeaway do you think? I think the main takeaway is to talk to our patients and explain why we're asking these questions more than anything else. Uh Something that would be, I think because there is obviously the obvious thing of being quite considerate and not being judgmental of anyone really. But that's part of our practice anyway. But, and I think it's part of the course if we're gonna be medical professionals, but I think it's very, very important that we explain why we're asking these questions. They are very invasive questions. It is an uncomfortable consultation to have having done the prep clinic myself. It takes a bit of practice. But I think really the best way to go about it, especially considering the history of the medical profession with hiding things from LGBTQ plus patients is to be upfront and honest and say I need to know these things. So I know what your risk is. So I have the information about what your sexual contact is like if it's a prep follow up, for example, you can say, well, I need to know these things so we can see what has been going on, how you've been getting on with your prep if you have any, if there's any risk, if there's any more support we can offer. So I think it's just the most important thing is just, just be honest and upfront about the fact that you are going to be asking some invasive questions because they are invasive questions regardless of whether or not we're the doctor, which we are. So they come in prepared for some invasive questions. But this is going to be quite a thorough, thorough history of their sexual contact. That's a good point, isn't it? Because we don't tend to explain much of the rationale for our own reasoning. And I think it's something I noticed with a patient the other day and they were coughing up blood. And I said, oh, so how are your legs and they're like, well, that doesn't make any sense, but obviously, they don't know what I'm thinking about. Is there a DVT? Is there a pe? Um So just explain your rationale in general is probably, I think it's very important, especially if you're asking a patient, the question of whether or not they're giving or receiving anal sex, that is a very invasive question to ask a person. So you have to be able to explain yourself and say this is why I'm asking you this as a reason behind it. Yeah, exactly. Um I think Taa said, um they'd love to hear about pep if you were happy to talk about that a little bit more. Yeah, I'll, I'll talk a bit about pep. Uh So I know a bit less about pep cause I've uh I've mostly my clinical experience has been in prep clinics. Uh But um what's important is to talk about, what is the kind of high risk HIV transmission scenarios. So, it's important to note that the highest risk behavior, the highest risk of exposure in HIV would be well, for having sexual contact with a patient, a person who's known to be HIV, positive. If they have a high viral load, obviously, your patient will have no way of knowing. They might have some way of knowing whether or not their partner has an undetectable viral load or not because there is more and more research to indicate that if a person has an undetectable viral load. The risk is quite low. Uh But regardless the highest risk of exposure comes from having, from being the receiver of either anal or vaginal sex without protection. Uh There's quite a low risk of uh being exposed to HIV through either digital penetration or oral sex, even for the receiving person. But obviously, if there are cuts in the mouth or sores or things like that, that increases the risk quite significantly. Um So these are the type, the, these are the people that we would consider to be at highest risk of exposure. Uh So there are other high-risk behaviors that we know of which is shops exposure, which we have in our own profession quite a lot uh as well as any type of sharing needles or anything like that. But that is that has nothing to do with pe PSE. So post prophylaxis after sexual exposure. Uh so it should be routinely offered. So there's kind of a, let's say gradient. So pep should be routinely offered to reduce the risk in the following scenarios which is following receptive anal intercourse with an index partner of unknown HIV status or to known to be HIV positive with either an unknown or detectable HIV viral load uh following receptive vaginal sex with a similar, the, the the same profile of a partner. Those are the two things that we need to consider. Uh That's, that's when PEP should be offered. Uh pep should be considered. Um if uh this pa if, if a patient has had inserted vaginal intercourse with an index part partner who's HIV positive with an unknown or detect or, or detectable viral HIV load. Um and also with inside of anal intercourse with a partner of unknown HIV status. So, if we know that our patient is at high risk, we need to routinely offer them. So, uh just a, an fy I, it doesn't really have quite a lot to do with sexual health. Uh But PEP is generally not recommended if uh in the case of human bites, if the index case is HIV positive with an unknown or detectable HIV viral load. Uh But overall, I think we would be most likely to do it as uh ALEC and I in the test from our own clinical practice. Uh Strangely, we do have an example of this. But um yes and PEP is the the first line regimen for PEP is the medication that I mentioned prior, which is uh 245 mg of tenofovir disproxil and 204 and 200 mg of uh triacetine fixed dose. Uh But it's also combined with Raltegravir, uh 1.2 g once daily and it lasts for 28 days. Uh There's also specific advice that any types of antacids, multivitamins and iron supplements should be avoided while being, while taking Raltegravir. Uh because of interactions. Uh There's quite a lot of that on the B NF as we know. And this should be baseline tests still done for these patients. So, creatinine of, of AU ne really for threatening EG Fr HIV antigen antibody test. Um Hepatitis B serology if our patient is not known to be I if we, if we don't know if they've been vaccinated for hepatitis B as well as screening for hepatitis. If they, because if they've had a high risk exposure, they are also at risk of other uh S TI S. And uh with regards to follow up uh follow up testing for HIV can be performed 45 days after the completion, completion of the PAP course. Uh If a 28 day course is recommended if a 28 day course is completed this a minimum of 10.5 weeks post exposure and for sexual exposure HIV can be undertaken at week 12 after the exposure to align with syphilis testing. So you can delay it because you would recommend syphilis testing as well for patients who've had a high risk exposure. Um Yeah, so you can also transition into taking prep after the prep course. So I believe after the 28 day four week course is completed, you can transition your patients into taking prep. I am not to be honest with you 100% sure if they do just switch, they just stop the other antibiotic, the other antiviral and continue with the standard medication that I mentioned, which they do start taking for pep anyway, or if there is any type of waiting period or bridging, I am not 100% sure, to be honest. Uh Are there any other specific questions you have about pep? Uh, anything else that you think I've not covered? Really? II know this is a bit of a, I don't have any slides to support this one, so it's a bit of a whistle stop tour like it. Um OK. I think I have one more question. I wanted to, uh uh to, to talk to you about which was say I've got um, a patient in clinic. Uh, and she's a woman who, she's only interested in women. Uh, she's only ever had like sexual relationships with other women. Um, w would, what would be her s ti risk? What should we sh what should she be concerned about or uh, well, for, for women who have sex with women, there is, there is also, there's quite a lot of, uh, very good NHS pages to advise them on this. But the ST is that are common, I believe. And for women who have sex with women are gentle, her herpes, gentle war, trichomoniasis, chlamydia and gonorrhea are also at risk, um, and can be transmitted with a between women as well as syphilis. Uh So I'm not aware that there are um, that there are any kind of STIs s that we would rule out for women who have sex exclusively with them. And we would still to my knowledge, screen for most STIs s if not all. Um, obviously, as, as we know, with regards to HIV transmission, as the highest risk activities are vaginal penetrative sex or anal penetrative sex. That would be, I suppose a reduced risk. But I, II do think that we might consider it in the context of either shared sex stories or things like that. But I do think that for all the rest of the S ti s we do have to consider it. And I think there's a, there's a preconception isn't there that, um, kind of, they're not at any risk potentially because if there's no, there might be penetration with sexual toys, but if there's no penetration from another partner, um, yeah, it's a reduced risk, that's for sure. But it is not a, it's not a nonexistent risk for contact for, for, um, for infection through oral sex. It is a very low, a much lower risk. Uh, but I do think that it is part of the regular sti screening anyway, in the sense of if you're going to do the screening already, uh to ensure that there's nothing going on there. But II do think that it's, it's unlikely mo more unlikely that they would be susceptible to it as the, the transmission risk is relatively, significantly lower. Um, that was also important to clarify that there's a question she's having sex with other women? But is she having o other sex with cis women or trans women? Because those are very different points, aren't they? Exactly. So that, that once again we get into the quite invasive questions that we need to ask of our patients sometimes. Uh, but it is important to know. Uh, and yeah, I, I'll put my email up there if anyone feels like sending me an email asking me anything. Um I know a bit about this. Uh I know a little about medical history and philosophy if you have any questions about that. Uh Yeah, I've got a list of our upcoming sessions and I also have a slide with, with my references, but also some sources for more information. So I'd just like to, I'll navigate back to this and the feedback, I'll, I'll leave the feedback link here for a second, but I've got some further resources here, which is really the couple of things that I wanted to talk about as resources that are very, very useful, both for us and for our patients is first of all, the British HIV Association. So they produce quite a lot of guidelines which I use for my prep part of my presentation. Uh They're very thorough, they make very good recommendations. They have quite a lot of good evidence base for all of the things that they say they have quite a lot of cited research through every chapter of their, of their guidelines and they update them quite regularly when I went to the nice guidance uh for these issues, I was directed back to the British HIV Foundation Guidance. Um So they, they have quite a lot of information uh for medical professionals as well. And uh there is also the Terrence Higgins Trust. So Terrence Higgins Trust was named after uh a man who died of AIDS in the eighties. And it's got quite a lot of information for both for us and for our patients about quite a lot of things. Uh they link to other things as well such as guidance and support for chem sex and risk assessment behavior. Uh and just one final thing with regards to chem sex and risky sexual behavior like that, it is always important to discuss any possibility of sexual assault with our patients in the context of se chem sex. It can be quite a risky situation, sexual assault. Unfortunately. So that is a subject that you should be aware of, be mindful of and think about with your patients. Uh, and the final thing that I wanted to talk about is uh a charity called Care Opinion UK, which I've used in my research in the past. It's a website that allows patients to talk about their experiences of healthcare organizations in the UK. So specific trusts, specific hospitals, specific clinics, specific wards, um some trusts pay for membership for their stuff. Uh and it is quite eye opening especially with regards to LGBTQ plus people, for example, gender affirming clinics and the experiences that people have had in this country because that is quite a big issue that we should all be aware of. Uh it's not particularly related to sexual health in and of itself, but it's an interesting resource. I think it's a good way for us to think about uh our practice and our patients and get some quite direct feedback from them if we're considering things. And yeah, that's all I've got. That's great. Thank you. Um.