Sexual health

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to sexual health by illustrating the key learning points with a case scenario and questions. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources. There is particular overlap between this Topic Guide and Maternity and Reproductive health and also Gynaecology and Breast Health.

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. As a GP, your role is to: 

  • Provide contraceptive services, sexual health screening, testing and treatment of sexually transmitted infections (STIs) and support partner contact tracing 
  • Be able to take a concise sexual history that enables risk assessment for STI, often in the context of patients who may not consider themselves to be at risk of STI 
  • Offer opportunistic sexual health promotion and risk reduction advice. Provide care which is non-judgmental and holistic recognizing the physical, psychological and social impact of good sexual health 
  • Be aware of the key legal precedents, guidelines, and ethical issues that influence sexual health care 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) 
  • Recognize 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 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 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 female genital mutilation 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 untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient 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) 
  • Sexually Transmitted Infections including chlamydia, genital herpes simplex, genital warts, gonorrhoea, human papilloma virus (HPV), sexually transmitted blood borne viruses (HIV, Hepatitis B and (rarely) Hepatitis C), syphilis and trichomonas

Sexual dysfunction

  • Female sexual dysfunction, including anorgasmia, dyspareunia, hypo-oestrogenism, 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 

  • Female genital mutilation (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 
  • Genito-urinary skin disorders including lichen sclerosus, balanitis 
  • Provision of, and access to, pregnancy termination services (including variation in this between the four nations of the United Kingdom) 
  • 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 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/ring contraception, progesterone only methods including oral, depot injection, sub-dermal implant, intrauterine systems (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 sexually transmitted infection 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 (BBV), 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 sterilization procedures
    • Access to emergency contraception
    • STI testing and access to 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); and 
    • Hepatitis A and B vaccinations for MSM and the use of Pre-Exposure Prophylaxis (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 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 Competence     
                           Questions       
Fitness to practice
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
How to I feel about repeated requests 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? 

Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for 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 don't adversely affect patient care? 

Am I aware of the GMC guidance on Personal Beliefs and Medical Practice? 

What are the legal issues regarding an abortion request? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

How might I explore Precious’s sexual history? How do I ask about the possibility of FGM? 

How does Precious feel about her unwanted pregnancy aabortion 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 interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
How do I confirm she is pregnant and at what gestation? 

How can I investigate for HIV or other sexually transmitted infections? 
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
What clinical examinations and investigations might be appropriate in this situation? 
Making decisions
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
How do I determine safely if Precious is at immediate risk of harm (for example, domestic violence)?  

How do I prioritise the various issues raised by this consultation? 

Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

What might indicate that Precious is being abused/coerced into sex-work? 

Is Precious at risk of any other health problems? 

What counselling options are available locally for women who can't decide whether to proceed with a pregnancy or have a termination? What conflicts of interest might these counselling services have? 

Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

What health promotion opportunities does this consultation present? 

How do I prevent another unwanted pregnancy in the future? 

How do I address STI testing, HIV testing, cervical screening, future contraception and any underlying psychosocial/sexual issues with this patient? 
Working with colleagues and in teams 
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
What other resources/services/healthcare professionals could I involve in the management of this case? 

Do local pregnancy termination services provide post-termination contraception or STI screening? 

Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 

 

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?  
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
How do I record sensitive information in the notes?  

What is the local referral pathway for women requesting an abortion? 

Practising holistically, safeguarding and promoting health
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

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 repeated abortion? 

How do we make our practices more welcoming for either gender to discuss their sexual health problems? 

Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

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 specialty trainee 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 to become familiar with the management of common problems. For trainees 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 e-Learning module(s) relevant to this topic guide at e-Learning for healthcare. The RCGP also has Sexual health e-Learning modules.  

Many postgraduate deaneries provide their own courses on sexual health problems. Other providers include BASHH (British Association for Sexual Health and HIV) www.bashh.org (who offer the Sexually Transmitted Infection Foundation Course – STIF) and the FSRH (Faculty of Sexual and Reproductive Healthcare) www.fsrh.org. The FSRH also provide a comprehensive course consisting of e-Learning modules, small group work and practical training, leading to an award of the Diploma of the Faculty of Sexual and Reproductive Healthcare (DFSRH). Interested trainees 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 specialty trainee 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 
  • HIV exposure prophylaxis

Clinical Skills Assessment (CSA)

  • Phone call: Father wants advice on how to react to his 12-year-old son who has doubts about his gender identity 
  • 25-year- old man attends with unilateral swollen painful testis 
  • 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

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