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

• 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. 

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

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.  

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 

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.  

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