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Hi, everyone. Welcome to this evening's Stash webinar on sexual health in young people. Thank you all for giving up an hour of your evening to come. My name is Tony Master. I'm one of the education reps for Stash. Um And if I can just remind everyone, first of all that straight after this event, you will be emailed a feedback um link. If you could complete the feedback form, it's really helpful both for our speakers. Um but also to inform our future webinars of what sorts of topics you'd like covered. And then that's also how you'll get your certificate at the end of the session as well. And I'll just hand over now to my co-chair. Kathleen. Hi, everyone. I'm Kathleen. I'm an F two and the seven Deanery Pres specialty ambassador for staff. Um I'd like to introduce uh um Doctor Hay Wood who's coming to talk to us today about sexual health in young people. So, she's been working as a consultant in HIV and Sexual Health in Derby for over 10 years. She's the clinical lead for young people within her service. And in this role, she attends young people's MDT and reviews practice um like safeguarding. She has special interests in recurrent candidate and genital dermatology and she is the Bash Clinical Governance representative for the Trent region. So, can I hand over to you? Hay? Hi there. So, um as a juice, I'm Hay and I'm one of the consultants in sexual health and HIV and I work in the Derby Derbyshire area and I've worked there for over 10 years now and my involvement in sexual health in young people um includes a few different aspects. So seeing young people in our clinics, um both um for contraception and those attending the sexual health needs. Um I also work within our HIV transition clinic. Um So working with the pediatricians in those people living with HIV, who are transferring from pediatric to adult service says I'm part of our young person's MDT, which is a group that we have um along with our sexual health promotion team, along with our health advisors, some of our nursing staff to look at how we're managing young people within our particular service, what we can be doing to, to get better, how many young people we're actually seeing and what those young people are coming to our service for, but also as a view of practice. So I look at all of the 13 year olds that attend our service um within the preceding three months and go through all of their notes to look at what happened to them when they came into our service that we took and whether there were any learning points and those learning points are then back fed back to our staff that are working in the clinic to try and improve our practice when it comes to looking after young people. Um So I'm gonna talk about a few different things today. So I just move my slide along. Hopefully that worked. Um So we're gonna look at um some common sexual health issues, think about social and psychological factors, think about confidentiality and hopefully think about how we might manage a young person that's presenting um to us either in a sexual health service or elsewhere. Um I think there's a couple of things I can see in the messages about problems with slides and things. Have you got your slides sharing at the moment? Hailey, I can see them on my screen. Yeah, I can see them. I can't see them. Is there anyone, are there any attendees who can see them? Because I can see the introduction slide. I can't see the slides on my screen. Um hm That is strange. Hailey. Are you able to try it to try it? And then Reshef um Yeah, I if I stop presenting, shall I and then um retry uh present now. So they're showing on my thing again, I can see them. Now. Can anyone confirm in the chat that everyone else can see them? Great, lovely. Yeah, thank brilliant apologies. And someone said that I wasn't, I wasn't very focused, but honestly, that's no great loss. I'm looking rather tired and I get this evening. So you're probably better if I'm not focused. Um, fine. So we can all see the signs brilliant. So I suppose thing to think about is why it's important to get it right when we're thinking about managing and looking after young people's sexual health. Well, I really important is that we want our young people to have healthy happy relationships. So if people are having relationships, they want, we want them to be healthy where they're happy in their relationship, where they've got effective communication where they're not feeling pressurized into anything and we're not, then that those relationships become unhealthy or even abusive. So we can really work with our young people to ensure that their relationships are healthy and happy and empower them into having healthy and happy relationships. So that's the, you know, the first thing that's really important, other things to think about are um important things like teenage pregnancy rates. And we can see here that these are the teenage pregnancy rates over the last few years and we have seen a, a decline in teenage pregnancies. And that's really important because when we think about teenage pregnancy, we know that um there can be some um kind of unfortunate outcomes. So, um if you think about those who have teenage pregnancies, po potentially they're more likely to feel isolated to be living in poverty have low levels of education and low levels of employment. Younger people are also at high risk of preterm birth and also low birth weight and a higher likelihood of having a termination of pregnancy. Um So this is where sexual house services are important in providing access to contraception, especially thinking about longer acting reversible contraceptives and providing an equity of care for, for young people so that they can access our services and thinking about how our services are, um you know, like the times of our clinic appointments and things because if you're thinking about young people who perhaps need to attend school, then they may not necessarily be able to come to appointments in the daytime. So we need to think about whether we have evening slots and also about whether walk in um slots are more appropriate than booked appointments. So these are all the things that we need to take into account when we're thinking about how we're running a service and, and providing access to young people. We also um in terms of getting it right, think about our ST rate. So, um we have seen particularly recently an increase in levels of sexually transmitted infections and that includes most sexually transmitted infections. So, if we think about chlamydia, particularly gonorrhea, we've had the highest levels since records began syphilis, we have the highest levels since post war. And we know that um a younger age group of people are more disproportionately affected when it comes to um, ST rates, there have been a few kind of win, win situations. So certainly we've seen after the advent of the HPV vaccination, a decline in diagnoses of things like um genital warts. Um So we are winning in some respects, but we know recently that we are seeing these increasing rates of sexually transmitted infections and we really need to try and reach out to the right people to get them to have screening and make sexual health an important part of their, you know, overall health, you know, like you would have a dental check up, you know, thinking about having a sexual health checkup. And when we think about some sexual health services and areas, we've had a real increase in things like online testing and so greater access to testing. But in some areas, those tests are limited to people who are a bit older. So I know certainly within where I work at under sixteens can't use our online testing service. And that was an agreement we have because of safeguarding concerns and because of trying to engage people and get them into clinic so we can cover all of their sexual health needs, not just the sexual health screening, but it does mean that perhaps it puts some people off testing if they can't access it online. Um like older teenagers, for example, uh just move my slide along and then we think about some of the other high profile things that we've seen in the news, so particularly when it comes to child sexual exploitation and there have been quite a few high profile cases around the country. So certainly In Derby, there was one a few years ago and um we've heard about the RO room case which um there have been a number of TV programs that have been made about this where particularly sexual health services were key to i identifying these young people who were being sexually exploited, highlighting it to um the police and working with those young people. Um So that's another reason for us to get it right, because we may be the only people that young um young patients will tell these, you know, important information to and it's about making sure that we then um feed the right information um to the right sources. And we are, you know, our young people are ever experiencing a different environment when it comes to sexual health. So, um you know, I was a youngster a long time ago, we didn't even have mobile phones at that point. And most young people these days have a mobile phone with easy access to the internet, with um access to apps, for example. And so they're much more open these days to sexual exploitation and to um you know, elicit sexual images um via, via their phones, um something in their own home. And that is also worrying. So part of our role needs to be about addressing how safe people are on, on the internet with um, websites and the information that they're giving across to others and how they're being approached by sexual contact. So where they're meeting their sexual contacts and whether it's online and we'll come to some of that in a moment. So I'm gonna just go through a couple of cases so that we can just perhaps work through some of the um issues that might be involved with those and, and these are, are made up cases but could realistically happen um if you were working in sexual health. So if we think about our first case, um we have an eight year old girl who is referred to the integrated sexual health service by her general practitioner. And um the um girl has presented to the GP with some lumps in the genital region and the GP thinks that these are genital warts. So firstly, there's a kind of few issues with this sort of case. Um in lots of services, you'll have pathways for Children. Um So certainly in our service, we don't see young people who are under the age of 13, um unless they've already been through a pediatric service or the young person's sexual assault referral service. So, but um we wouldn't initially see this person in our service. We would be referring them to um the pediatric team or the young person's sexual assault referral service. And then if they needed some help managing those warts, then we would do that in conjunction. And you usually see the young person with the pediatrician in a child friendly environment. So we try not to bring Children into our um sexual health service or appointments if this person needed seeing for management of their general or what we try and do that in a pediatric setting where there are play specialists and it's just a much nicer environment for them. But when we think about sexually transmitted infections in Children, so we know that um sexual abuse and sexual assault should be considered in any child presenting with any genital warts, especially under the age of 13. And it does um you know, dictate a referral to child protection services. If they're over 13, then it would be on a case by base um kind of whether you would report it to um child protection services. And I think that would be taken into account lots of the other things that we're gonna talk about later. And this is similar for infections like gonorrhea, chlamydia and trichomonas. Now in, in Children, about 31 to 58% of Children with anogenital warts. It was thought that sexual transmission was thought to be the cause of infection, but the evidence doesn't really distinguish at what age vertical transmission should be excluded. Um So we know that there is vertical transmission of HPV virus. Um We know that that can cause things like respiratory papillomatosis in babies. But it, we really don't know at what age it become. It, it's not a problem anymore if, if you do have vertical transmission and, and Children develop genital warts. So really, they should be initially um dealt, you know, managed as this could be a marker of sexual abuse. And, and therefore for these Children being managed by a specialist pediatrician with an interest in sexual abuse and um and non consensual sex, that's really important. So usually, as I say, um these sort of cases wouldn't be managed within our particular sexual health service and it might be different around the country. But certainly this um child would need multidisciplinary approach with the pediatricians with um child protection services and also then management of the actual wars and that might involve um the sexual health consult, seeing the patient along with the pediatrician. So moving on to kind of more of the bread and butter of what we might see in our sexual health services. Um So this is a 15 year old female and she comes to the sexual health service for an implant fit. She comes alone, she is fit and well, she's not taking any medication and she wishes to start on contraception. So I just want a few people to put in the chat things that they might think of or might think we need to do if we're looking after this um 15 year old female. So some of the things that you might want to think about, some of the things that we might need to do. So just fire a few things into the chat. Ok. Brilliant. So some really good answers there. So I think certainly, um, you know, all of those things are things that we would need to ask about. Um, so you've know about, see, you've thought about what type of sex they're having, you've thought about safeguarding concerns. S ti screening gil competence. Brilliant. So yes, lots of different um answers there. So firstly, we need to think about confidentiality. So um in all of our services, we will have a confidentiality policy which should be clearly displayed and also should be discussed with the young person that's attending your service ideally at the beginning of the consultation. And usually that confidentiality policy is that anything that they tell us will be kept confidential unless they discuss with us something where we feel that they're at risk of harm. And then we may need to share that information with others, including for example, um social care or child protection services. So, discussing confidentiality is important. Um We have got something in there. People have about um gil competence. So what is this? So essentially um quite a few years ago, there was a um court case where a GP has set round a fire about contraception in under 16 year olds and this all went to court and essentially it was decided that Children under 16 can consent to their own treatment if they're believed to be intelligent enough competent and understanding, to fully appreciate what's involved in their care. And that's known as Gille Competence Fraser guidelines extend that a little bit further to ap specifically to advice and treatment around contraception and sexual health when speaking to a young person who's under the age of 16. So for a young person under the age of 16, to be fraser competent, then they would need to um you know, the things on this checklist would need to apply. So that's that the young person will understand the professional's advice that the young person cannot be persuaded to inform their parents that the young person is likely to begin or to continue having sexual intercourse with or without contraceptive treatment. And that unless the young person receives contraception treatment, their physical or mental health or both are likely to suffer and that the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent. So this is a really important thing to assess for our young people that attending the service that they are gil or or Fraser competent so that we can be, we can be providing contraceptive care for them without informing their parents. And certainly in lots of services you will have performers, as somebody's mentioned that there is a performer and on our performer, we do have this tick list where we tip to agree that yes, this young person that we're seeing is good at competent and they have um satisfied the Fraser checklist. So somebody has also mentioned about safeguarding. Um And that's really important with any young person that we're seeing, especially as mentioned with these high profile cases about a child sexual exploitation. And this is a definition of child sexual exploitation that it's a form of child sexual abuse. It's where an individual or group takes advantage of an imbalance of power to coerce manipulate or deceive a child or young person under the age of 18 into sexual activity in exchange for something the victim needs or wants that could be financial advantage or increased status of the perpetrator or facilitator, facilitator. Um I doesn't always use physical contact and kind of occur through technology and I'd already mentioned about um mobile phones. So there are lots of different signs and indicators of possible child exploitation. And so the questions that we're asking a young person in clinic are all are involved in looking at whether this young person has any signs or indicators of possible child exploitation. And also whether they have any risk factors that make them more likely to be a victim of child sexual exploitation. So we're wanting to know are they already being exploited or are they at increased risk of being exploited if they're already being exploited, then that will require um referrals to child protection services and police and if they're at risk of exploitation, what can we do to stop that young person being exploited? So what other additional help and additional support can we put into that young person to prevent these things happening? So we fill in a CSE checklist and this comes from the spotting, the signs checklist which includes lots and lots and lots of different questions, but they're all really important and their, their aim is to try and pick up these markers and some of them can be really subtle. So they can include um physical um indicators. So if somebody is self harming or they're having um attempts at, at, at harming themselves or a suicide, if there's been some unexplained changes in their appearance or behavior, if they're presenting with sexually transmitted infections, recurrent um urinary tract infection symptoms, they're presenting with things like pelvic inflammatory disease. It can also include psychological factors. Um So some of those are li listed here. So we might see um our young people developing mental health problems, we might see that they are suffering from low self esteem and low self confidence and low self worth. They may present with eating disorders. Um So anorexia or bulimia, um they may have posttraumatic stress disorder as a result of the um the sexual exploitation that's already happened and they may have kind of chaotic lifestyles. They may be living in a chaotic house where there are other issues or adverse um childhood events occurring such as parental substance abuse or alcohol use and all of these things are included in the pro performer. And ideally when we're seeing a young person in clinic, the aim is to try and ask about all these um things, but in the context of trying to put it into a conversation with them because the performers are often quite long, it's often quite a lot of questions. And if you're just firing off the questions, one after the other, then one of the young people that you're seeing can get really annoyed and fed up. And two, they may become, you know, more, more withdrawn and, and feel like they can't talk to you about things. So there is a, a bit of a knack to making sure that you've got enough time. Firstly, um that you're not rushing this and that also you're making it into a conversation where you're interested in what the young person is saying and doing and interested in their, in their life. So the proforma asks about general things according to their lifestyle. So, are they at school? Are they going to school regularly? So if young people are perhaps playing truant and not going to school, we need to think about, well, where are they going when they're not going to school? Are they playing and hanging around the streets that can put them at increased risk of sexual exploitation? Because then people who are older can come along and pick them up in their cars and take them off um to hotels or to other places. So truanting and not getting on at school um is a, is a risk for sexual exploitation. If you think about how they're getting on at school. If they're being bullied at school, if they're not making friends, if they're feeling lonely, then that can lead to low self esteem and low self, low self confidence, which is a, a risk factor for sexual exploitation. We think about their home life. So who is it that they're living with? Um If they're not living with both parents, why might that be if they're a child who is under the care of social care? Why is that, what's happened for them to be um living in shared accommodation or to be living in foster care? Are they happy at home? Are there any problems at home? Are they, do they get on with their parents? Do they get on with their siblings? Is there any domestic violence within the house? Is there somebody in the house that they can talk to about their worries and concerns? Um Is there somebody that they can talk to about sex? Have they got a, a figure at home who they can discuss about having, you know, starting on contraception or sexual contact or having happy, healthy relationships and have they got examples of happy, healthy relationships in their life or are the relationships that they're witnessing or involved with those unhealthy relationships or those abusive relationships. So, what is their starting point in terms of knowing what healthy relationships are? Um, we also investigate things like alcohol and drug use and that's, um, their association with that and their sexual contact. So, are young people drinking alcohol and that's when they're having their sexual contact or are they taking, um, drugs and that's when they're having the sexual contact or is it, um, the, you know, the other way around that they're having sexual contact in order to get drugs or alcohol from somebody? So, are they, um, is somebody going to buy them drugs and alcohol in exchange for them doing sexual activities? So we want to explore the relationship between alcohol and drugs and their sexual relationships and then certainly we need to explore those relationships a bit further. So who is it that they're having sexual contact with? Are they somebody who's the same age? Are they somebody that they've met through school or they've met through friends at school or more worryingly? Is it somebody that's approached them on, um, social media? Somebody that they don't know who's approached them on Snapchat or one of the kind of fun dangled apps these days and that they've just gone to meet out of the blue and where are they going to meet these people? Are they traveling to different cities around the country by themselves to meet somebody that they don't really know, or they've not met before. Um, is it that they, they, you know, they're meeting them in their own home and there's adults around, are they meeting them in public places? So, some of the young people that we talk to are actually going to local parks and having sexual contact. And so, you know, we really need to be inquisitive about the types of relationships and the types of sex that people are having and who they're having sexual contact with. And when we think about, you know, any imbalance in power, so are the people that they're having sex with much older? Um, are they in a position of responsibility? Is it, um, a teacher? Is it somebody in the local scout group? Um, they're just so, you know, we need to think about who it is that they're having sex with and are they happy in those relationships? Is there any worry about those relationships? Are they concerned about how that person's treating them, how that person behaves when they're with them, how that person makes them feel and also how their friends feel about that person? Because if their friends don't like them, why is that, is, is it that their friends are worried about them? Is it that their friends realize that this isn't a healthy relationship? Um So there's lots of different things that we explore. And as I say, this can take quite a time when you're in clinic. So when you're thinking about young people's services. One of the things that you need to think about also is the length of time of the appointment. Um because the the checklist does take quite a lot of time, it can raise lots of issues that you perhaps need to explore with the young person and need to work on further. So let me just move on my slide. Um So these are again, some more signs. So we've talked about this. So being absent from school or being included, staying away overnight. So if, if young people are running away from home, where are they going? You know, why, why have they run away from home in the first place? Is it that they're um experiencing violence at home? Is it that they're not getting on with their parents and where are they going when they're running away? Importantly, where, where is it that they are um going to receiving gifts from unknown sources, gang members or affiliation with gangs and this is where things like county lines come into play. So where young people are exploited um for taking drugs to more rural places and selling drugs. Um and also kind of young people withdrawing themselves from then their usual group of friends and changing groups of friends. So these as we discussed, most of these already are the risk factors for child exploitation. So um Children who are in care, Children who have already gone through adverse childhood events, Children who have been previously sexually abused. Um, bereavement of a significant person in their life can be associated with it. Um, living in poverty, neglect, um, substance abuse and parental substance abuse and um gang association. So this is the checklist that most actual house services will use spotting the signs and that was developed by Ba Bash and Brooke. So if in that checklist, we identify any safeguarding concerns, then we don't just write them down and ignore them. We need to do something about those and that might involve a referral to child protection services. It might an early referral to social care. It might involve discussing that with our local safeguarding teams if we're not really quite sure what to do. And so discussing it with our trust safeguarding experts as to what they feel is the next best course of action. And if we're identifying any of those risks for developing CSE, what can we do about those? So if a young person is, is experiencing mental health issues, are they under the care of um child and adolescent mental health services? Can we refer them to C A MS? Can we involve their GP to help with assessing their mental health? Um Can we involve the school nurse in helping with that? And there are some apps and things available for young people. Um So there's lots of different apps associated with helping with things like anxiety and low mood and also um like just checking in and, and improving their own mental wellbeing. Um If we think that our young people have an issue with drugs and alcohol, then we can refer them to drug and alcohol services. Um, if our young people have already undergone sexual abuse or sexual assault, then involving the young people, sexual assault referral centers and also some of the support services for people um for counseling after they've been sexually assaulted or sexually abused. So, the proforma is designed to identifying if there's already a problem or that somebody is at risk in the future and helping us to plug in services to that young person to keep them safe um and healthy in the future. So the other thing that we thought about with this young person is the actual contraception bit itself and certainly people have discussed about pregnancy tests and things. So anybody that we're starting contraception, we need to do a full like medical sexual gynecological history. Um just to elicit. When did they last have sex? When was their last period? Are they having regular periods? Is there a pregnancy risk? So do they need a pregnancy test? Do they need emergency contraception? Um Before we actually give them a, a longer form of contraception, we think about medical problems specifically, um that will be included in the UK MEK eligibility for. So for those who don't work in contraception at the moment, on the FS Rh website, there is a document called the UK MEK eligibility. And essentially this is a document which lists lots of different medical problems uh against the different types of contraception and gives you a rating of 1 to 4. So one is that there's not deemed to be any risk from that contraceptive um type and that medical problem, whereas A four is that the risk would be deemed to be greater than the benefit of the contraception itself. So every time we're thinking about starting people on contraception, we're thinking about, do they have any medical problems? And where does that fit in with the UK MEC eligibility for actually receiving that type of contraception? I mean, our young people would be discussing the different types of contraception available and you'd be surprised at kind of the lack of information that young people have already been given about contraception, about um you know, sexual health and contraception teaching that's given in schools. We we are trying to improve that certainly. Um with our local authority, we're trying to improve the the standard of sexual health training that's given to a sexual health discussion that's given to youngsters at schools. But there really is a, a variation depending on where you are in the country. And also if you think about young people that may have um moved to the UK from other countries where sex education is not on the agenda in any of their schools, nobody talks about sex education. So they may be coming to the UK with a very different level of understanding. One, they may not even know what sexual contact is, but also have never really discussed with anybody about how you can have safer sex or, or what contraception is. So you're really trying to, when you see a young person assess their level of understanding what do they already know and or what is it that they, you know, they know about contraception and what else do they need to know? So we don't want to talk about the different methods available so that then they can make a informed decision about which type of contraception would be the best for them. And then we provide that um contraception and in the case of this, it was an implant fit. Um So provide a young person can understand what the implant is for the um benefits behind it. The risks. Then we can do that procedure without having the parental consent because they've got their Gilli and Fraser competence and whatever form of contraception we have, we need to think about appropriate follow up. So for most people having an implant fitted, it works for three years and we can perhaps breathe a sigh of relief that they've got their implant in, but they may come back with side effects or problems from the implant that need reviewing um commonly people can get irregular bleeding and sometimes that can become problematic bleeding if we're thinking about contraception provision of pills. For example, we really need to think about whether that young person is going to remember to take them. Um We might want to book them for a follow up to review their contraceptive use and, and actually how they're getting on with that pill. Are they remembering to take it? Because if they don't remember to take it, then it's not going to be efficacious and it's not going to work and they may end up pregnant. So I think that probably covers without going into great detail about contraception, which isn't the remit of this um presentation. And then we've discussed about kind of sexual health and, and screening. Um So for anyone that comes to an integrated sexual health service, we should be thinking about all of their sexual health needs ideally in the same appointment. So, although this young person's come for an implant fit, we do need to think about sexual health screening as well. So that would involve taking a full sexual health history. So when was the last time they had sex? Are they having sex with? What type of sex they're having? Are they having oral sex or anal sex or vaginal sex? We need to think about risk factors for bloodborne infections. So, are they born in a country where um bloodborne infections are more common? Are they having sexual contact with people who are from a country where they're more common? Are they injecting drugs or sexual partners? Injecting drugs. Um, do they have a sexual partner who's known to have a bloodborne infection? Um, and then we can deduce from our full sexual history, what we need to do in terms of screening. So everybody should be offered HIV and syphilis testing. And one thing I would say about the young people, particularly that we see in our service is often they are reluctant to have a blood test, they're scared of needles, they don't want to have a blood test. But there are other ways that you can think about testing for these things. So in our service, we have point of care tests available. So that's a finger prick test which sometimes is more um favorable to a young person. Um And ours test for HIV and syphilis. They don't, all, some of them are just HIV testing alone. Um We have oral HIV testing kits in our service. So if somebody can't tolerate the finger prick test, then they could have an oral swab. But really, we encourage them to have um full testing. So HIV syphilis, hepatitis B and C. Um if there's risk factors and then chlamydia and gonorrhea testing from any site where that's appropriate. So if people are having oral sex and anal sex, they might require pharyngeal or rectal sampling. And if a young person is symptomatic, then they might need additional testing. Um If they've got genital ulcers, then we might need to consider things like herpes testing if they've got urinary symptoms, thinking about doing a urine analysis or an MSU, um just really depending on the symptoms they're presenting with. And this is an opportunity to promote safer sex advice for the future. So, thinking about condom use, are they using condoms at the moment? If not, why not? Is it that they don't know what condoms are? Is it that they don't know how to put a condom on? So, just simple questions that they might have been afraid to ask anybody else, but you're giving the, the opportunity to be able to, to talk about it. So we can do things like condom demonstration. We can do promotion about vaccinations that young people might need. So have they had their HPV vaccination at school? Um So we definitely know that it's a, a really worthwhile vaccination. It's decreased the risk of cancer of the cervix but also of visible genital warts. So if they've missed out, like they've not been attending school and they've missed out, can we then organize them um for them to have a catch up HPV vaccination? Do they need Hepatitis B vaccination? Are they at risk for Hepatitis B acquisition? Are they having multiple sexual contacts? Are they um having sexual contact with um people who have known Hepatitis B or from a country where hepatitis B is more common and we can give them advice about things like post exposure prophylaxis, which is a medication that people can take for 28 days to reduce the risk of HIV after a potential exposure or prep, which is pre exposure, prophylaxis, which is a medication that people can take if they're HIV, negative to reduce the risk of them acquiring HIV. So it gives us an opportunity to promote healthier, safer relationships for the future. So I've already sort of mentioned about this that from our consultation with the young person, we've had identify if there's any other services that are needed, do they need some extra support from the general practitioner? Do we need to involve mental health services? Do we need to involve other community services, drugs and alcohol? Um In Derby, we have a really good service called Safe and Sound. And they work with young people who have either been sexually exploited or are at risk of, of um child sexual exploitation. So where we've perhaps identified that a young person is using social media in a way that perhaps risky. So sending photos um where they're not got clothes on, um where they're engaging in sexual behavior online where they're being approached by people online to meet up then safe and Sam will work with that young person to try and address that risky behavior and try and um kind of get them to see why people might be concerned about them going to meet random people in different cities around the country. Um the school nurse um can be really valuable, especially if a young person is having problems at school with things like bullying and reluctance to go to school or worries around their, their mood. There are lots of mobile apps for things like pill reminders. If you're worried about someone's compliance with their contraceptive pill depo reminders that can remind them to come for their depo injections and also um apps around helping to manage anxiety and, and mental health problems. We have the young person sexual assault referral service. Um So if somebody does present to our service, um if they're a young person under 13 and they're sexually active, then we initially would make sure that they are referred to the police and to the young person's sexual assault referral service. But sometimes, then the young person's SARC will refer to us later down the line. So once a person's had their initial assessment, their initial forensic examination, but they need some screening or they need some further vaccinations, then they'll get referred back to us. We have the trust safeguarding teams who are always there for advice. So we don't always know the answer to everything. Things crop up that we're not sure about, but it can just really help to discuss with somebody else and to discuss with the safeguarding teams what they would recommend and what they were, what they would advise. And um sometimes, unfortunately, we do need to refer to child protection services and social care if we think that child um is in need or a child is at risk of harm. So, what's our framework for managing young people and sexually transmitted infections? Well, we have got the bash national guidelines on management of sexually transmitted infections and related conditions in Children and young people. And this kind of includes lots of things that I've already talked about that. We need a holistic approach to young people under 18. We need to be assessing their vulnerability for self harm, mental health. Um We need to be doing a risk assessment such as spotting the signs. We should be working towards your welcome quality standards, which are Department of Health Standards for making services, young people friendly. And that's thinking about your accessibility, confidentiality, the environment where you're seeing the young person, um any staff training, attitudes and values. Um We need to think about our confidentiality policies, which I've already talked about encouraging sexual health screening, thinking about domestic violence, particularly with looked after Children. So I would say that a large proportion of our young Children, younger um people that we see in our service are already under the radar of social care and are looked after Children. So they may be in foster care, they may be living in supported accommodation. So when we see those people, it's really important for us to take contact details of their key workers or their um social worker. And we do usually feedback them to the social worker just to check in sometimes the social workers will be really helpful in getting that young person to come to clinic. Um Sometimes if you're really struggling to get a young person in the social worker can assist with that and help the young person to physically get to the clinic to their appointments. And um thinking about unaccompanied asylum seeking Children. So one of the um large number of referrals that we have are from the um asylum seeking GP. So the GPS that look after unaccompanied asylum seeking Children and as part of their um kind of routine and things when they arrive in the UK. One of those is that I'll be referred to sexual health services for sexual health screening. And we are often, they are um from countries where things like hepatitis B are endemic and are at much increased risk. And you will find that when these young people come to clinic, some of them have never been sexually active, but they are at risk of um vertical transmission. Some of them may have been sexually assaulted on their route to the UK, which is often AAA common finding and they need some psychological support and help around that and they're at risk of sexually transmitted infections. And then some of them will really have no clue about sexual health because they come from a country where it's not really talked about, they don't have sex education in schools. And so all that they know is really what they've found out from other people. And so really, then we need to ensure that um, their social workers are making sure that they're having some form of sex education, you know, even back to the very basics so that when they come here and they, um, do start having sexual relationships, then they can be more well equipped to making those safe and healthy and happy relationships. So I think I've come to the end. So, are there any questions at all or anything he wants to ask or talk about or anything that you want to know that I haven't covered? Um, as Tony said, please feel free to pop any questions in the chat and then we can read them out for everyone. Um, Haley, I had a question was just from the start that graph you showed about the rising prevalence of various sexually transmitted infections. I was wondering if there are any different patterns you see in younger age groups compared to older age groups. Like, for example, syphilis I know is rising nationally and I wondered if that's the same in these, in these under eighteens as it is in the older population, if there's any variety there? Yeah, I think, I mean, certainly, um, you know, the chlamydia rates are increasing in all age groups, but particularly in the young, you know, we know that it's much prevalent in the, in the younger age group. So the 16 to 25 year olds gonorrhea is definitely increasing in that same age group. But when we think about our syphilis, um prevalence rates, usually it's the age group that are a little bit older. So, although it is increasing in younger people, I don't think it's to the same extent as for example. So the the rates in syphilis do seem to be much more in that age group. The 25 to 40 year olds, I think it is um except for if we think about um perinatal infection. So because we're seeing a rise in syphilis in adults, um we are, we are expecting that we will probably also see a rise in congenital syphilis. So we know that in the UK, all women are screened antenatally for syphilis if they accept the screening. Um But what we then might miss are those people that acquire syphilis in pregnancy. So, antenatal screening is done around booking, which is about 10 weeks in the UK. But if people have a new sexual partner during their pregnancy, then potentially they can acquire syphilis and have vertical transmission and it's not detected. And so that's, you know, one of the things to consider um especially when we're seeing pregnant women and sexual health services that, you know, even though they've had a booking blood, you know, repeating their HIV and syphilis screening, there have been some new guidelines that have been introduced recently um for women that present with a rash in pregnancy. So if women are presenting with a rash in pregnancy, making sure that mid, mid, you know, the midwives and GPS that are looking after them are thinking about syphilis testing. Um because we know that that's why we're missing some, some women. Um and also obviously those that don't engage with antenatal testing. Um So I think of genital syphilis, potentially, we could see, you know, a real increase and a real problem with that in the coming couple of years, with the rise in syphilis, generally in the population. But in terms of kind of S ti s in the like, you know, 16 to 25 group really is, you know, chlamydia is the commonest and then gonorrhea rates that are increasing. And I think that, uh you know, it's difficult to say what's caused that is it that there's a lack of sex education. And I think the answer to that probably is, yes. So I think, you know, if any of us are parents that we should have a responsibility to our teenagers to discuss, um, you know, healthy relationships, then I think schools really need to come on board with proper sex education. Um and making sure that they're giving the right information. I think about how we're targeting and promoting sexual health to youngsters and how they're accessing services, um, condoms, you know, just, you know, simply what is a condom. How do you use it? Where can you get them from? And there have been some really good schemes nationally like the C card scheme, which is where young people can access free condoms. Um People can order condoms online from sexual, some sexual health services or drop into clinics and access them f um free. Um Yeah, I think that's about it. II so I hope that sort of answered the question. Thanks. Hailey and Varin had a question very broad in your experience. Has the COVID pandemic affected young people's sexual health. And if so how, so I think COVID has affected current of sexual health services massively in a huge number of ways. So we definitely saw in COVID that our sexual health services were decimated, that lots of services had staff redeployed elsewhere. Firstly, so that lots of services were running a very minimal sexual health um service usually either for people who are symptomatic or those that really needed to be seen. Um So we know that there were much less appointments, we know that testing moved online for lots of people. And again, as I say, there were a, there are age limits in some parts of the country for online testing. II know particularly in our service. Um under sixteens can't test online. And I think that um sexual health services have sometimes found it very difficult to get reestablished after COVID. Um I know certainly in my area, we stopped our walk in clinic. So before COVID, we had walk in clinics every day, COVID happened and we couldn't do that. We did, you know, a hybrid of telephone triage bringing people in who are symptomatic. And then when we just started to get over COVID, we had the OX outbreak and so that also affected services because, um, we didn't, we felt a bit uneasy about having walk in clinics with people who might be coming in with ox, especially at the beginning when we didn't really know much about it. Sexual health physicians weren't really ox experts back then. It was sort of a new thing. We'd never seen it before. We didn't really know what to do with it. And so lots of services were probably a bit worried about having waiting rooms full of people where they might have somebody sitting with ox, you know, transmitting infection to others. And, you know, we've developed over time, we now have become more of an expert in M Park and we certainly, you know, know how to recognize it, but it did change our triage processes at that time and it did make us a bit worried about um having walk in clinics and I think, you know, lots of services now are getting back on track with increasing appointments with increasing um, walk in services. So I think COVID definitely had an effect from that, that respect. I think COVID also meant that perhaps people's ways of developing relationships change because none of us were allowed out anywhere. And so you weren't kind of mixing socially as you might normally do. So, what do you do then? Is you kind of revert to social media? So I pre you know, people may have been spending more time on social media, may have been um experiencing more online kind of sexual exploitation. So I think there's a few different factors. COVID COVID certainly decreased um S ti rates. But was that because of decreased testing and rates of infections have certainly gone up since um COVID well ended, I should say, but it hasn't really ended. But since the end of the pandemic, we are now doing more testing, but I think we're seeing still more infections than we are testing if that makes sense. Thank you. Um And I've got a question from um Campbell. What would you suggest would be the biggest intervention that could be made to improve rates of testing in young people? I think it's difficult because if I knew that we would be doing that in our service. But I think education at schools is just key because that's where young people are, that's where they're going to go. And so educating them at that point in time about the importance of sexual health screening and about having regular check ups, but also how to access services, I think in the local area. Um I don't, outreach probably is the other thing, you know, whether um services have sexual health promotion teams that can go and do outreach and go out to colleges, go out to other settings where there are young people. So sports clubs, um other and, and do testing events, getting out to university events. But I think, uh you know, funding is always an issue that um sexual health services are, haven't had their budget increased. And so when you think about where the money's got to go, um not many services have a lot of spare money to spend on sexual health promotion. Thank you. Um, myself and Kathleen will ask one more question each and then we'll wrap up the session. Um, how do you build a rapport and get a thorough sexual history from a young person who might be shy or embarrassed. And if you have a limited amount of time, I think, um, a limited amount of time is, is all, you know, is one of the kind of barriers and we're all kind of overworked and busy and rushed. But I think trying to take time where possible sometimes chatting about other stuff. So, you know, having an interest in that person thinking about what activities they like doing, what hobbies they have. So, while you're trying to do your other stuff in having, building up a little bit rapport about other things. So, you know, usually I'm sort of chatting about their trainers that they've got on driving. Feels a bit of report. I mean, I do try and pretend I'm a bit cool, but I'm really not. And there's always new words that spring out that I'm like, I really don't, you know what that means or what that is or, you know, so try to keep a little bit up to date with like, you know, TV, programs, music, fashion, that sort of thing. Often like to, people have wonderful nails when they come in, you know, one of the things working in sexual health and in hospitals is you're not allowed to have gel nails. Everybody seems to gel nails. So if they have like just getting them to engage about how amazing their nails look is always a good starter. So anything that you can find to find like a common interest that will get them talking and feel like they can have a bit of a normal conversation with you, even though lots of the other stuff that you're talking about is really quite intimate. So, yeah, it, I don't know, I find myself having lots of weird conversations about things like mcdonald's, for example, you know, if they've come in with their mcdonald's bag or they've got some, you know, some item of clothing on or they've got their music on their headphones on or you know, what is it you're listening to or what, you know, what, what you're doing at college, you know, any sort of random chit chat, I would say they sound like good techniques one last question. So is there and for the management of S TI S are there any major differences between treatments for adults versus pediatric cases? Not many differences? I mean, if you think about, um, pediatric treatment things, um, it's just about, you know, lots of antibiotic dosing as according to weight. Um, lots of our young people that we see aren't really going to be much smaller than I am, to be honest, but really just checking the pediatric B NF and also the bash guidelines do stipulate the kind of dosing of medications um for each sexually transmitted infection, but there aren't hu huge amounts of differences to be honest. Perfect. Thank you so much, Dr Wood for such a clear presentation on such an important and relevant topic. Thank you to all the attendees um for giving up your evening to come and listen. I've popped the link for the feedback form in the chat and it will also be emailed out to you as well after this session. And as I say, if you could fill that in, then it helps us to build our program and you will also get your attendance certificate as well. Um So thank you again, everyone and I will let you go and enjoy the remainder of your evening. Take care. Bye.