The role of the GP in sexual health
Sexual health is concerned with enabling an individual to experience enjoyment of sexual activity without causing themselves or anyone else physical or mental harm. It is also concerned with contraception and sexually transmitted infections (STIs). As a GP, your role is to:
- provide contraceptive services, sexual health screening, and testing and treatment of STIs, and to support partner contact tracing
- be able to take a concise sexual history that enables risk assessment for STIs, often in the context of patients who may not consider themselves to be at risk of STIs
- offer opportunistic sexual health promotion and risk-reduction advice. Provide care that is non-judgemental and holistic, recognising the physical, psychological and social impact of good sexual health
- be aware of the key legal precedents, guidelines and ethical issues that influence sexual healthcare provision, especially regarding patients under 16 years of age in relation to consent and confidentiality, and at all ages in relation to confidentiality, abortion, sexual assault, coercion and female genital mutilation (FGM)
- recognise that gender, gender identity, gender dysphoria and sexual orientation are all different facets of a person’s health and that issues relating to these may present in childhood, adolescence or adulthood and have a wide influence on wellbeing
- provide care and support for women with unwanted/unintended/unplanned pregnancy and for women requesting or having undergone termination of pregnancy.
Emerging issues in sexual health
- Teenage pregnancy rates in the UK are falling but remain the highest in Western Europe.
- People who experience gender dysphoria, including children and young people, may increasingly present to GPs.
- The incidence of STIs is changing (for example, reduced incidence of genital warts, increased rates of syphilis and antibiotic-resistant gonorrhoea).
- There is debate surrounding the effectiveness of the chlamydia screening programme and of human immunodeficiency virus (HIV) screening in high-prevalence areas.
- HIV continues to be one of the most important communicable diseases in the UK. General practice has a role in caring for patients with HIV and assessing the risk of having undiagnosed HIV. PrEP (Pre-Exposure Prophylaxis) is likely to become increasingly used to protect high-risk individuals from becoming HIV positive.
- The prevention, recognition and reporting of FGM and the legal duties relating to this, as well as the subsequent psychological, sexual and pregnancy issues that may arise, should be understood by GPs.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care
- prognosis.
Symptoms and signs
- Abnormal vaginal bleeding suggestive of infection including post-coital and intermenstrual bleeding
- Dyspareunia
- Dysuria
- Erectile dysfunction and premature ejaculation
- Feelings and behaviours related to gender dysphoria
- Genital ulcers and warts
- Pelvic and abdominal pain
- Penile discharge
- Psychosexual dysfunction, including anorgasmia, loss of arousal, loss of libido and vaginismus
- Systemic manifestations of STIs (for example, reactive arthritis, rash)
- Vaginal discharge
- Vulval pain or irritation
Common and important conditions
Infections
- Bacterial vaginosis
- Candida
Infestations (including pubic lice and scabies)
- Pelvic inflammatory disease (PID)
- STIs including chlamydia, genital herpes simplex, genital warts, gonorrhoea, human papillomavirus (HPV), sexually transmitted blood-borne viruses (HIV, hepatitis B and (rarely) hepatitis C), syphilis and trichomonas
Sexual dysfunction
- Female sexual dysfunction, including anorgasmia, dyspareunia, hypoestrogenism, loss of libido and vaginismus
- Male sexual dysfunction, including erectile dysfunction due to organic causes (such as diabetes, drug-induced (including smoking), neurological disease and vascular disease) and psychological causes. Premature ejaculation
Other
- FGM, including practical and legal aspects, reporting mechanisms and protecting girls at risk of FGM
- Gender identity, dysphoria and reassignment, including children and young people
- Genitourinary skin disorders, including lichen sclerosus, balanitis
- Provision of, and access to, pregnancy termination services (including variation in this between the four UK nations)
- Sexual abuse and assault (both adult and child), including care of patients who have been abused and indicators of assault (including STI in children).
- Child sexual exploitation
- Unwanted/unintended/unplanned pregnancy and termination of pregnancy (including legal and ethical aspects)
Examinations and procedures
- Male and female genital examination (including bimanual pelvic examination and speculum examination)
- pH testing for bacterial vaginosis
- Vaginal swabs: use of ‘self-taken’ samples (vulvo-vaginal and urine) for chlamydia and gonorrhoea; indications for clinician-taken swabs
Investigations
- Investigation of STI: swabs, urine and blood tests (including timing of testing, practicalities and interpretations of results)
Other important content
- Empirical management of vaginal discharge
- Female contraception, including:
- hormonal contraception: combined oral, patch and ring contraception, progesteron-only methods including oral, depot injection, subdermal implant, intrauterine system (IUS)
- non-hormonal contraception: cap, diaphragm, female condom, intrauterine device (IUD)
- long-acting reversible contraception (LARC)
- sterilisation
- emergency contraception
- Male contraception, including condoms, spermicides, vasectomy
- Methods of natural family planning
- Prescribing for patients taking HIV medications from specialist clinics, including drug interactions
- Safe sex advice, sexual health promotion and risk reduction (adults and young people)
- Screening for STIs including chlamydia and HIV
Service issues
- Access to gender identity clinics and care of patients with gender dysphoria in primary care, including sensitive record-keeping and appropriate use of titles and personal pronouns
- Access to sexual health services for individuals with learning or physical disability or with different communication needs
- Awareness of local prevalence of HIV and blood-borne viruses (BBVs), including some awareness of overseas prevalence as relevant to international patients
- Consent and confidentiality in respect of under-16s accessing sexual health services (Fraser guidelines)
- HPV vaccination programme
- Local and national strategies to reduce teenage and unplanned pregnancies
- Local service arrangements for:
- provision of LARC services and sterilisation procedures
- access to emergency contraception
- STI testing and access to genitourinary medicine (GUM) clinics
- patients presenting following sexual assault
- Provision of sexual health promotion services, including:
- health promotion and ‘safe sex’ advice, particularly in higher risk groups (such as young people, men who have sex with men (MSM) and sex workers)
- hepatitis A and B vaccinations for MSM and the use of PrEP
- Screening for domestic and intimate partner violence in the context of sexual health consultations
Case discussion
You work in an inner-city London practice. The first patient of the morning is Precious Lam, a 26-year-old who arrived in the UK two years ago as a refugee from Sudan. You note she attends infrequently and has had two early pregnancy terminations since registering with you. She has come to see you today because she has missed her last period and is requesting another abortion. She was last seen six months ago when she was given a three-month supply of the combined oral contraceptive pill by one of your colleagues.
You try to explore her history, but she seems reluctant to answer you and seems to be avoiding eye contact. There is no evidence of any previous STI testing or cervical screening.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How to I feel about more than one request from a woman for termination of pregnancy? How would my attitude towards Precious be influenced if I learned she was a sex worker? Or a victim of sexual abuse? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | Do I have any personal ethical objections to dealing with sexual health matters such as abortion, certain methods of contraception and methods of fertility treatment? How do I ensure these objections do not adversely affect patient care? Am I aware of the General Medical Council (GMC) Personal beliefs and medical practice guidance1? What are the legal issues regarding an abortion request? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How might I explore Precious’s sexual history? How do I ask about the possibility of FGM? How does Precious feel about her abortion request? She is reluctant to answer questions – how do I determine if there are issues she feels unable to discuss today? How do I explore why Precious did not continue with her contraceptive pill? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | How do I confirm she is pregnant and at what gestation? How can I investigate for HIV or other STIs? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What clinical examinations and investigations might be appropriate in this situation? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How do I determine safely if Precious is at immediate risk of harm (such as domestic violence)? How do I prioritise the various issues raised by this consultation? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What might indicate that Precious is being abused or coerced into sex work? Is Precious at risk of any other health problems? What counselling options are available locally for women who cannot decide whether to proceed with a pregnancy or have a termination? What conflicts of interest might these counselling services have? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What health promotion opportunities does this consultation present? How do I prevent another unwanted/unintended/unplanned pregnancy in the future? How do I address STI testing, HIV testing, cervical screening, future contraception and any underlying psychosocial or sexual issues with this patient? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | What other resource, services and healthcare professionals could I involve in the management of this case? Do local pregnancy termination services provide post-termination contraception or STI screening? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What is my plan for keeping up to date with current management of STIs and contraceptive choices? What are the current local and national priorities in the area of sexual health? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How do I record sensitive information in the notes? What is the local referral pathway for women requesting an abortion? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | Am I aware of the particular health needs of refugees and asylum seekers? Are there any local services specifically supporting these population groups? What might be the psychological impact of more than one abortion? How do we make our practices more welcoming for either gender to discuss their sexual health problems? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | If I was looking to evaluate and develop my local sexual health services, how would I begin to do this? Does this case highlight an unmet need in the local community or health service? Am I adequately informed on the issue of modern slavery? |
How to learn this area of practice
Work-based learning
Primary care is the best place for a GP registrar to learn how to manage sexual health because it is where the vast majority of patients present. Patients will present their concerns and symptoms at varying stages of the natural history. Experience gained under the supervision of an experienced GP, with an opportunity to discuss and reflect on cases, will build expertise in this area.
Some GP specialty training programmes contain placements of varying length with sexual health or family planning clinics. These placements will help you to: see concentrated groups of patients and learn about sexual health issues involving men and women, including transgender patients; become proficient in history-taking and clinical examination in this field; and become familiar with the management of common problems. For GP registrars without a dedicated sexual health placement, it would be worthwhile to arrange to attend some sessions at one of these clinics.
Self-directed learning
You can find eLearning module(s) relevant to this topic guide at elearning for healthcare. The RCGP eLearning site also offers sexual health modules.
Many postgraduate deaneries provide their own courses on sexual health problems.
Other providers include British Association for Sexual Health and HIV (BASHH), which offers the STI Foundation Course (STIF), and the Faculty of Sexual and Reproductive Healthcare (FSRH). The FSRH offers a comprehensive course consisting of eLearning modules, small group work and practical training, leading to the award of the Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH). Interested GP registrars can also obtain letters of competence in subdermal implants (LoC SDI) and intrauterine techniques (LoC IUT). Both BASHH and the FSRH have clinical guidance available on their websites.
Learning with other healthcare professionals
As a GP registrar it is essential that you understand the variety of services provided in the community. Joint learning sessions with practice nurses and specialist colleagues in sexual health clinics will help you gain a greater understanding of both the services provided locally and the need for cross-agency communication and partnership working.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Appropriate use of LARC for different scenarios
- Investigation of vaginal discharge
- Diagnosis of genital skin abnormality
Simulated Consultation Assessment (SCA)
- Phone call: a father wants advice on how to react to his 12-year-old son, who has doubts about his gender identity
- A 25-year-old man attends with unilateral swollen and painful testis
- A 31-year-old mother of two children requests help with low libido
Workplace-based Assessment (WPBA)
- Consultation Observation Tool (COT) about contraception for a teenager who has infant twins and is having unprotected intercourse
- Observed clinical examination and procedural skills (CEPS) on genital examinations for men and women
- Learning log on health promotion in a patient under 25 years of age for STIs