- Good history taking will aid diagnosis
- Use of open and bridging questions can help break the ice
- Motivational interviewing can enable behaviour change
During recent years, sexual health services have risen to the challenges relating to increasing incidence of sexually transmitted infections (STIs). The needs of the client group vary according to factors such as gender, age, sexuality and ethnicity, and some groups are disproportionately at risk.1 Indeed, many people continue to be at risk as a result of their sexual practice despite significant improvements in access to genito-urinary medicine (GUM) clinics, community services and general practice in recent years. This article is aimed at practice nurses who are presented with a female patient who requires an STI screen.
Pursuing sexual health can be a challenging prospect for many women. Anxiety around confidentiality, stigma, being judged, not using the appropriate language and undergoing intimate examination can make the experience uncomfortable if the consultation is not managed in an empathetic manner, and the nurse is ideally placed to reduce stress levels during the patient journey. Issues associated with screening women for STIs may be complex, and there are emerging ‘at-risk’ groups. The over 40s are now seen as an at-risk cohort as chlamydia, gonorrhoea, syphilis and human immunodeficiency virus (HIV) have been reported in older adults.2 Risk factors including psychosocial changes, re-entering the dating scene, decreased vaginal lubrication and infrequent use of condoms contribute to this at-risk group.3,4
Women may attend for a screen in a sexual health clinic or in primary care for several reasons. These may include a routine screen, new partner, unfaithful partner, itching, pain, bleeding between periods, ulcers, or lumps and bumps.
Breaking the ice
The initial greeting, including a warm introduction, maintaining eye contact and appropriate body language, sets the scene for a successful consultation by making the patient feel at ease. The reason for attendance is the initial starting question. Asking an open question such as “How can I help you? Do you have any unusual symptoms?” may enable free discussion and rapport with the nurse. Appropriate language and terminology should be used, even slang where necessary.
Lesbian women, sex workers and other marginalised groups may find it difficult to discuss sexual practice, and may feel more at ease if the clinic waiting area contains inclusive posters, and if staff demonstrate a welcoming and friendly attitude. However within the general practice arena, breaking the ice and asking intimate questions can be daunting.
It is kinder to focus on less sensitive questions such as last menstrual period rather than launching straight into the questions around intimate sexual practice. The use of “bridging” questions which link general lifestyle questions to sexual history questions can also be helpful for example “Do you have a regular partner? Do you have a new sexual partner, are you planning to have sex with a new partner when you go on holiday?” will more easily enable the history taker to ask the questions recommended by British Association for Sexual Health and HIV (BASHH). Closed questions will help identify any specific problems which can be further elaborated upon and aid diagnosis.
Sexual history taking
Minimum female history taking should include:
- Date of last sexual contact.
- Gender of partner.
- Anatomic sites of exposure (oral, anal, vaginal or a mixture).
- Any partner infection.
- Total number of partners in last three months.
- Previous STIs.
- Last menstrual period (LMP), menstrual pattern, contraceptive and cervical cytology history.
- Pregnancy and gynaecological history.
- Blood-borne virus risk assessment and vaccination history if at risk.
- Past medical and surgical history.
- Medication history.
- Drug allergies.
- Agreed method of giving results.
- Any competency/safeguarding issues.
- Alcohol and recreational drug history.
- Consider gender/intimacy-based violence.
- Women and men are asked if they have paid for or accepted money/gifts for sex.
- Other sexual practices may be explored if necessary, such as:
- Participation in group sex.
- Use of social networking websites to find sexual partners.
- High-risk venues.
- Receptive fisting.
- Traumatic sexual practice.
- Use of sex toys.
For a symptom review, women are routinely asked specific questions such as unusual vaginal discharge, vulval skin problems, lower abdominal pain/dyspareunia, dysuria, unusual vaginal bleeding including post coital and inter-menstrual bleeding.5
A chaperone should be offered for initimate examinations, and may also be an asset for passing swabs, or helping the patient feel more at ease. The gender of the clinician should be accommodated where possible. A standard STI screen will test for chlamydia and gonorrhoea as a combined swab using a self-swab from the vagina if the patient is asymptomatic, and the patient offered a blood test for syphilis and HIV.
If the patient is symptomatic, a visual inspection of the genitalia and speculum examination is required to sample from the cervical os. Additional swabs may include high vaginal swab (HVS) that will test for candida, bacterial vaginosis and trichomonas vaginalis in the event of unusual discharge, and herpes simplex virus (HSV) if there is genital ulceration. A pregnancy test may be performed and will be a consideration in relation to any prescribed treatments and ongoing management/referral.
The patient is shown into the examination room and given privacy to undress, and a modesty sheet available. It can be extremely traumatic to undergo a sexual health screen and the patient’s emotional stress may be projected onto the staff, who should be prepared for this. The use of an engaged sign on the door will further reassure the patient, and help them feel that the time and space is theirs.
The patient is examined in the lithotomy position using a good light source. The inguinal glands are palpated and pubic hair examined for lice. The labia minora are separated and the meatus and para-urethral ducts visualised followed by inspection of the genital tract including vulva, perineum and thigh for any lesions such as warts or ulcers.
The Bartholins glands are noted and may be palpated for swelling. The speculum is inserted in to the vagina and the characteristics of the vaginal and cervical surface noted, the vagina is rugous (ridged) and moist. Transwab culture samples from the vaginal wall may be taken for candida and bacterial vaginosis, and from the posterior fornix to test for trichomonas vaginalis. The cervix usually looks pink, feels firm and mobile without lesions and the os may be round or slit-shaped. A nuclear acid amplified test (NAAT) sample from the cervix should be taken to test for chlamydia trachomatis and neisseria gonorrhoea. Other anatomical sites such as throat and rectum may be examined and sampled depending on the sexual history and symptoms.
There should be an agreement as to how the patient will receive their results, within seven days, eg. phoning, text messaging or follow up appointment. In the event of positive results, the patient may be referred to the sexual health clinic for treatment and partner notification. The treatment given is free of charge in a sexual health clinic. The information given should also be supported with any relevant leaflets for the patient to read. Managing the patient during this time may be fraught with emotion, anger and anxiety if the patient has been unfaithful or discovered that their partner has been. It is always important to remember that people are not simply bringing their genitals to us, there are often additional emotional issues.
Being empathetic and gently forwarding a handy box of tissues to the patient will acknowledge the distress felt. With this in mind, it is important that the correct information is given about the aetiology of STIs is correct, bearing in mind issues such as domestic violence; for example, the appearance of genital warts or herpes ulcers acquired in the distant past may occur if the patient is a bit “run down, stressed or tired” rather than as a result of recent acquisition.
Preventing infections and motivational interviewing
The attendance is an opportunity to give good sexual health advice, including access to condoms. In some cases it is also worthwhile exploring the circumstances which lead people to make decisions about their sexual behaviour which they may later regret or suffer health related consequences, eg. use of alcohol, recreational drugs, holiday sex or self-esteem issues. Repeating harmful behaviours may be addressed with motivational interviewing which has shown to be beneficial in a wide range of healthcare settings, whereby the patients voice their intention to change, rather than being lectured or being told to change. Patients sometimes appear ambivalent or unmotivated, and healthcare professionals who advise change using a directive style may generate resistance or passivity in the patient. Motivational interviewing fosters a better relationship between clinician and patients and leads to better outcomes, Rollnick et al (2000).5
A sexual health screen can be a daunting process fraught with emotive issues. There are several tools that the nurse can utilise to minimise the anxiety by supporting the patient through the history taking and the examination. Successful outcomes enable accurate diagnosis and treatment, opportunities for health promotion including behavioural changes and a relationship where the patient is more comfortable when accessing sexual health screening presently and in the future.
3. Johnson BK. Sexually transmitted infections and older adults. J Gerontol Nurs 2013;39(11):53-60.
4. Bodley-Tickell A, Olowokure B, Bhaduri S, White D, Ward D, Ross J, Smith G, Duggal H, Goold P. Trends in sexually transmitted infections (other than HIV) in older people: analysis of data from an enhanced surveillance system. Sex Transm Infect 2008;84:312-317.
5. Rollnick S, Butler C, Kinnersley P, Gregory J, Mash B. Competent Novice, Motivational interviewing. BMJ 2000;340:7758.
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