INTRODUCTION AND OVERVIEW

Sexual health medicine is generally thought of as primarily concerned with the management of sexually transmissible infections (STIs). While STIs are an important facet, sexual health also includes a wide range of other topics including fertility and contraception, sexuality and gender, sexual problems and various dermatological and gynaecological conditions. Sexual health physicians are also involved with the public health aspects of STIs, particularly the reporting, monitoring and control of infectious diseases.

The vast majority of sexual health should (and does) take place in primary care—a point agreed on by sexual health physicians, general practitioners (GPs) and their professional bodies alike. GPs are well placed to provide the majority of sexual health services, and are the favoured first point of contact for most of the community. Sexual health is an important part of providing holistic care.

Specialised sexual health services are best utilised for the management of more complex STIs and genital syndromes, and for servicing high-risk populations and those who experience barriers to accessing primary care. Sexual health services can provide GPs with clinical advice and formal medical education, as well as useful information about local epidemiology, and can assist in the management of disease clusters.

The integrative approach is well suited to primary care management of sexual health. Preventive counselling and holistic lifestyle approaches resonate particularly well with best practice in the assessment and management of sexual difficulties, STI prevention and the management of chronic viral infections.

COMMUNICATING WITH PATIENTS ABOUT SEX

We are exposed to a constant stream of sexualised messages. Advertisers use sex to sell almost every conceivable type of product. The print media is littered with stories about sex, whether about sex crimes, advice on how to improve one’s sex life or appraisals of a celebrity’s sexiness. Electronic media are packed with messages about how we should look, how our relationships should work and how interested we should be in sex. Radio advertising tells us how much happier we would be if sex lasted longer, penises were harder and libidos were higher. As well as showing us what our genitals should look like, the internet even tells us which particular facial expressions should be worn during intercourse. Novels, television shows, music lyrics and video clips, newspapers, graffiti, unsolicited emails, magazines, movies, ring-tones, train platforms, pop-up spam and bus stops: messages containing sex are everywhere.

Despite the constant stream of sexualised messages, talking meaningfully and frankly about an individual’s personal sexual matters remains difficult for many patients and healthcare professionals. Open, confident and personal communication about sexual matters is not well entrenched in most societies, and may be more difficult with individuals from some cultural and religious backgrounds. Despite this, facilitating effective communication about sex is professionally rewarding to the provider, can be a therapeutic intervention in its own right and is appreciated by anxious patients.

The exhaustive list of questions to ask during a full sexual health history is shown in Box 61.1. Such a history is really only suitable for sexual health clinics and special circumstances such as symptomatic or otherwise high-risk patients. There is growing appreciation that a full sexual history for all patients in all scenarios is unnecessary and intrusive, and yields false responses from a significant proportion of patients—an observation that would probably not surprise most experienced GPs.

A recent Australian study illustrates this point well.¹ The authors examined the attitudes of women to chlamydia testing in general practice. Acceptance of age-based chlamydia testing was high, but women did not want to be asked to provide a sexual history as part of being asked to have a chlamydia test. Some reported that they would lie if asked how many partners they had had. The authors conclude that chlamydia screening in general practice needs to be normalised and destigmatised.

That having been said, there is still a place for more detailed sexual histories. In some settings, such as sexual health clinics, patients expect to be asked about their sexual histories and are not surprised or unwilling to offer a response. Similarly, patients who present with genital symptoms or have previously had an STI might reasonably expect to be asked about their sexual history.

The aims of sexual history taking depend on the clinical scenario. For patients presenting for sexual health testing, the history should focus on the presence of symptoms and the risk of STI acquisition. The history will help to determine which tests to take, and tailor the extent of pre-test counselling. A history for sexual problems is often more wide-ranging and includes assessment of relationships, stressors, mood, sexuality, physical problems, medications and so on.

An asymptomatic patient attending a general practice setting, or one whose symptoms are not obviously related to sexual health, might be more surprised by a line of questioning directed at their sexual history. A patient who presents to the GP with a maculopapular rash, for example, might not suspect syphilis as the cause.

It falls to the person taking a sexual history to employ non-intrusive strategies that distinguish low-risk from high-risk settings, and then alter the direction of the history accordingly. This is a complex task, and it is reasonable to initially find the process daunting. The task, however, gets easier with experience and practice. In turn most patients will read the comfort level of the interviewer and respond in kind: the interviewer who can respectfully and confidently collect an intimate history provides an obvious cue for the patient to respond with similar openness and confidence (see Box 61.2, for example).

Doctor–patient power dynamics can lead to the patient feeling it necessary to please their healthcare provider. Sensitivity in history-taking, and listening to cues from the patient, will avoid the assumption of heterosexuality. Simple clarification of partners as male, female or both will facilitate disclosure.

Patients might expect that unsafe sex will be displeasing or disappointing to healthcare professionals and minimise the risks they report. Providing a non-threatening space for the patient to honestly disclose an accurate sexual history is better than an authoritarian, judgmental response. Similarly, focusing on finding tailored solutions is more effective than focusing on the problems.

Patients who are diagnosed with an STI should be counselled on the route of transmission, strategies for prevention and (where applicable) partner management.

SAFER SEX AND STI PREVENTION

The World Health Organization ranks unsafe sex as the world’s fifth most prevalent cause of mortality.^2,3 This includes mortality from HIV infection, consequences of pregnancy (predominantly lack of access to safe abortion and contraception), cervical and anal cancers and bacterial STI. Disease acquired through sexual activity accounts for 0.5% of the burden of disease in Australia.⁴ Lower rates in developed countries are attributable to education, access to contraception (particularly condoms) and safe abortion, cervical screening and better healthcare for those who acquire STIs.

Condoms have become an integral part of safer sex strategies. Used consistently, they provide excellent protection against HIV transmission, as well as other STIs spread through infected secretions, such as gonorrhoea, chlamydia and trichomoniasis. Protection against those infections transmitted via skin and mucous membrane contact, including herpes virus infection and human papillomavirus, appears to be less. Condoms are also reasonably effective as a contraceptive method. Compared with most other contraceptives, they are readily available, inexpensive and safe.

Between 16% and 20% of Australian couples reported using condoms with their regular partner in the previous 3 months, and condom use was higher with casual partners than with regular partners. Gay men reported higher rates of condom use than heterosexuals. Condom use has increased significantly among people having sex for the first time.⁵

Common problems with condoms include slippage, breakage, loss of erection and reduced spontaneity. The most common problem, however, is simply not using them. Problems of slippage and breakage are usually related to lubricant: either using an oil-based lubricant, or not using any lubricant. Storing condoms in hot places, using expired condoms or not applying condoms correctly can also contribute. Ill-fitting condoms, either too tight or too loose, might break or slip more readily. For those with latex allergy, polyurethane condoms are available. Not only are these condoms as effective as latex, they transmit heat and sensation better than latex, and are less likely to degrade with heat.

Abstinence, like condoms, is effective only if used consistently. While celibacy is a valid personal choice for some people, there is incontrovertible evidence that it is ineffective as a public health strategy to reduce STIs or unintended pregnancies.⁶

Primary care presents many opportunities for introducing safer sex messages. Consultations about contraception, Pap smears, sexual health checks, STIs, genital dermatology and so on can lead to a discussion about safer sex. In the safety of a confidential consultation, patients respond well to being presented with an opportunity to ask questions about safer sex, and this can segue into assessing their understanding of safe sex. A combination of verbal and printed information gives patients the opportunity to review information later.

Identifying problems with consistent condom (or other contraceptive) use represents a golden opportunity to engage in preventive activities. The topic can be introduced with non-threatening questions that give patients permission to report problems. For example: ‘Have you had any problems with condoms?’ can lead to identification of specific problems.

The urges that humans experience to engage in sex (including unsafe sex) are powerful, and not always amenable to rational thinking strategies. Sometimes, however, unsafe sex can be a symptom of other underlying problems—mental health problems such as depression or mood elevation, low self-esteem and issues of dependence, alcohol or recreational drug use or sexual abuse are worth considering when patterns of unsafe sexual behaviour are identified.

SEXUALLY TRANSMISSIBLE INFECTIONS

Sexually transmissible infections are caused by a diverse group of organisms. They range in size from viruses, usually measured in micrometres, to ectoparasites such as pubic lice, which are visible to the human eye. Their life cycles differ enormously, and may include stages of latency, asymptomatic carriage, systemic spread, immune evasion or neural invasion. Some are extraordinarily well adapted to coexist with humans and cause their host such little damage that they are spread widely from person to person. Some cause disease so severe that they damage their own chances of onward transmission by causing disabling symptoms, or even remove their host from the population altogether.

What these organisms share is the exploitation of normal human behaviour: sex. For STIs, sex represents a way to breach the gap from host to host without having to deal with the extremes of temperature, desiccation, ultraviolet radiation and sheer distances that usually separate one host from another. For some pathogens, this is further facilitated by transport directly to target sites of the new host within warm, buffered, nutrient-rich media such as semen and other genital secretions.

Current treatments for STIs are, wherever possible, single high-dose treatments in order to ensure adherence and minimise the induction of resistance in other flora.

Below is a brief description of the sexually transmissible organisms that are more commonly encountered in most affluent countries.

SYPHILIS

Treponema pallidum infections have made a spectacular resurgence in urban communities in recent years. Globally, syphilis remains endemic in most of the world’s population. Primary syphilis presents at the site(s) of inoculation with an ulcer. Secondary syphilis presents weeks to months later with truncal rash, rash on palms and soles, malaise and occasional involvement of the eye, meninges, liver and other organs. Tertiary syphilis occurs after many years (sometimes sooner, in immunosuppressed patients) and represents an immunological reaction against organisms in the brain, spinal cord, blood vessels and heart, skin, bones, joints and many other soft tissues. The recent urban epidemic of syphilis has centred on MSM. Syphilis is epidemic among many rural Indigenous communities, and the few cases of congenital syphilis in recent times have arisen from here. It is diagnosed by serological tests and by polymerase chain reaction (PCR) (where available). Syphilis is treated with injections of penicillin G, to which it remains sensitive.

FIGURE 61.1 Secondary syphilis on the sole of the foot

MOLLICUTES

Mycoplasma genitalium is a sexually transmissible organism of emerging significance. It has been associated with male urethritis, cervicitis and pelvic inflammatory disease. Testing, treatments and contact management are yet to be standardised, although the regimens used to treat non-specific urethritis will effectively treat most infections. Liaison with a sexual health physician is recommended advice.

FIGURE 61.2 Primary herpes

Ureaplasma urealyticum is a sexually transmissible organism that is associated with male urethritis. It is usually managed successfully by the agents used to treat non-specific urethritis.

ASYMPTOMATIC SEXUAL HEALTH CHECKS

Chlamydia, gonorrhoea, syphilis, HIV and hepatitis B are frequently asymptomatic, but nevertheless can be transmitted to others. These particular infections also carry significant public health implications.

Screening strategies are justifiable when a condition is common, has serious consequence, can be readily tested for or can be managed effectively. STIs share these features to varying degrees.

STIs are not evenly distributed throughout the population. Several groups in the community experience higher than average rates of STI. Focusing screening strategies on those at highest risk makes testing more cost-effective and lessens the chance of yielding excessive false-positive tests in low-risk populations.

The sexual health history is the tool by which primary care providers can determine whether an asymptomatic individual is suitable for screening, and helps to determine which tests to perform.

Urogenital:

Serology:

‘Window periods’ exist for serological tests, and tests may need to be repeated once the window period has elapsed, to completely exclude infection after a particular exposure:

GENITAL SYNDROMES

Several sexually transmissible agents can affect one anatomical site and induce similar pathological processes, or syndromes. Rather than discuss organisms separately, it seems sensible to group them together by the nature of the syndromes they cause. This approach has the added advantage of better matching the way patients present.