Introduction to Sexual Health

Sexual Health goes beyond just the mechanical motions of sexual intercourse, and encompasses much more, including but not limited too; relationships, gender identity, contraception and pregnancy, infectious diseases and sexual assault.

This post provides just a brief introduction to the world of Sexual Health, particularly looking at Sexually Transmitted Infections (STIs)/Diseases and Blood Borne Viruses (BBVs).

Key Resources

Rather than my traditional way of keeping the goodies to till the end, I have provided some key open access resources specific to STIs which I think should not be overlooked.

- STI Tool

- STI Atlas

- Australian STI Management Guidelines

Approach

The NSW STI Programs unit has put a nice simple approach together for clinicians to follow in STI assessment and management.

1. Start the conversation about Sexual Health.- Consider approach language for that demographic
   - Ensure a safe environment
   - History and assess risk factors
   - Examination as appropriate
2. What and how to test your patients.- Testing based off earlier assessment and population groups
   - Consider most appropriate method of testing (e.g. swab, urine, blood test)
   - Opportunistic testing (e.g. doing a high vaginal swab, whilst doing a Pap Smear)
3. Contact Tracing- Prevent re-infection for your patient and the onward transmission of the disease.
   - Understand the timeframes for specific STIs
   - Using the appropriate resources to contact trace and inform third parties

NSW STI Programs unit's four page quick cheat sheet is available here.

Rules of Sexual Health

1. Assume nothing. 
2. All STIs can produce disease without causing symptoms.
3. More than one STI or BBV can be present
4. Do not presume that the presenting genital problem is the only problem.
5. Respect difference.

Sexual Health History

The importance of communication and language can and should never be down played in consulting, however it is particular important in Sexual Health. The correct use of language can make; people feel comfortable opening up to you on topics that might be very personal to them, feel validated and that you understand them as a person and their associated identity, help them risk mitigate and manage their own condition moving forward. Clarifying the language the patient uses regarding genitals and what sexual intercourse means to them is also important step.

For example in Men who have Sex with Men (MSM) in regards to anal sex, you may want to find out who is penetrating and who is receiving. These terms may for them personally, and it will sometimes require more simple or vulgar language -> “Did you fu*k him in the butt or did he fu*k you?”

Below are some areas to get you started and think about. I am however, not expert in this area so I've included a link to the Australian STI Guidelines take on Sexual History Taking.

• Regular Partners
• Other Partners
• Nature of Sexual Contact
• Condom Use
• Past history of STI
• Overseas Contact
• Sexual function difficulties
• What age did the patient first experience sexual contact
• Of course for all females; are you or is there a possibility you could be pregnant.

Aside from taking a more focussed Sexual Health History, you still need to cover your standard Past Medical History, Allergies, Medications, Social History and so on.

I have always like the HEEADSSS psychosocial interview and despite being designed for adolescents I think it can be often used and adapted if required for any age of life. In the context of sexual health, I think that it can a useful tool to assess factors that may positively or negatively influence their sexual health. In addition, guide appropriate testing and management strategies that are more applicable to that individual.

H – Home 

E – Education & Employment 

E – Eating & Exercise 

A – Activities & Peer Relationships 

D – Drug Use/Cigarettes/Alcohol 

S – Sexuality 

S – Suicide and Depression (including mood &possible psychiatric symptoms) 

S – Safety (also Spirituality)

If you are really floundering in what to ask for in a Sexual Health History or just like something short and snappy to remember than think of The 5 P's for Sexual History.

P artners 

P revention of Pregnancy 

P rotection from STDs 

P ractices 

P ast History of STDs

The CDC has developed this little handout that goes in to the 5 P's a little more.

Common Sexual Health Diseases

Prevalence of the various STIs is dependant upon the region in which you live and work. However, there are a number that are fairly common globally which I will cover below.

Like most things in life, be aware of what is going around in your local patch, and the strategies that are used locally.

The Quick Guide to STI Management from Western Australian Department of Health covers nearly all the common sexual health diseases. Remember to check your local guidelines as well, however this is short and succinct document if all else fails.

Asymptomatic Testing

Tests for all sexually active people.

• Chlamydia (males):  FPU - NAAT
• Chlamydia (females): Endocervical swab – NAAT , Self-collected vaginal swab – NAAT , FPU – NAAT, Ano-rectal swab 

Consider the following tests for individuals who are not from a high risk population group. To determine risk, take a sexual history.

• Hepatitis B: Blood – HBsAg, Anti-HBs, Anti-HBc 
• HIV: Blood – HIV Ag/Ab 
• Syphilis: Blood – Syphilis serology 

Additional test to consider in asymptomatic individuals;

• Gonorrhoea: NAAT and/or Culture

Also give the STI Tool a go to help determine what test you might need.

Population Groups

For more details regarding Sexual Health assessment in particular population groups
click below;

Aboriginal and Torres Strait Islander people 
Adult Sexual Assault 
MSM - Men who have sex with men 
People in correctional facilities 
PLWHIV - People Living with HIV 
Pregnant Women 
PWID - People who inject drugs 
Refugees (and newly arrived migrants from similar settings) 
Regional/Remote 
Sex workers 
Transgender 
WSW - Women who have sex with women 
Young people

A Career in Sexual Health

Interested in a Career in Sexual Health Medicine in Australia? See the Royal Australasian College of Physicians for more details about how to expand your skills in this area.
This flyer provides a brief overview of the program.

References and Resources

1. The 5 P's for Sexual Behaviour History Taking: https://aidsetc.org/resource/5-ps-sexual-behavior-history-taking
2. STI Tool: http://www.mshc.org.au/Portals/0/Documents/HealthProfessional/STITool/stiTool1.7.pdf
3. STI Atlas: http://stiatlas.org/SearchAtlas.aspx
4. STI Guidelines: http://www.sti.guidelines.org.au/
5. ReachOut.com: https://au.reachout.com/relationships
6. CDC - A Guide to Taking a Sexual History: https://www.cdc.gov/std/treatment/sexualhistory.pdf
7. NSW STI/HIV Testing Tool: https://stipu.nsw.gov.au/wp-content/uploads/STI-HIV-Testing-Tool-online.pdf 
8. Western Australian Department of Health - SilverBook Guidelines for managing sexually transmitted infections and blood-borne viruses: http://ww2.health.wa.gov.au/Silver-book