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Let's talk about sex!

Training is the key to successful healthcare delivery and research has shown that nurses who have received sexual health training are more likely to bring up the subject without becoming embarrassed. Sarah Challinor argues that it is time to put sexual healthcare on the general practice agenda

Sarah Challinor
BSc(Hons) Dip(HE) RN
Contraception and Sexual Health Nurse
(Previously Practice Nurse)
Eastern and Coastal Kent PCT

Sexual health continues to be high on the public health agenda - the recent publication of STI figures by the Health Protection Agency suggests that infections such as chlamydia, genital warts and herpes are continuing to rise. Chlamydia rates increased 166% since 1997, but encouragingly rates decreased slightly in 2006 in certain age groups suggesting that the safer sex message is beginning to work.(1)

Policy and guidance
The workload at genitourinary medicine (GUM) clinics is rising - there was a 9% increase in screening in 2006 - and the traditional settings of GUM and family planning may not be adequately resourced or accessible enough to tackle the sexual health crisis alone.(2) The Department of Health recognised the limitations of GUM in England with the publication of The National Strategy for Sexual Health and HIV in 2001 and Choosing Health (similar documents have been published in Wales and Scotland).(3-6) The main aims of the strategy are seen in Box 1.

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The strategy identified general practice as the typical first point of contact for most patients and emphasised its value in improving sexual healthcare. Indeed, a large study identified that 40.5% of patients attending GUM clinics had already consulted their GP, many of whom could have been successfully managed in general practice.(7)
General practice should be providing a minimum of "level one services" (see Box 2). Provision of level one services has not been audited nationally; however, a recent study identified that of 22 practices, none were providing all level one services.(8) It is reasonable to suggest that few provide all of the required services, and it is likely that the most frequently provided are contraception and cervical cytology screening as they are remunerated via the nGMS contract.

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The importance of prevention has not been forgotten; recent NICE guidance states that professionals working in general practice should be routinely identifying those at high risk of STIs and providing structured discussion to reduce risks.(9) What is important in these guidelines is the clear emphasis that identification of risk can be made by all health professionals; however, intervention to reduce risks should only be provided by those with sexual health training.

The case for general practice
Sexual health services could be effectively implemented in the same way that general practice embraced diabetes and asthma. Practice nurses are well placed to provide sexual healthcare as they are viewed as approachable and well qualified.(10) Additionally they have proven themselves to be adaptable in an ever-changing healthcare system and it is sensible to suggest that practice nurses could provide much of the level one services.
The evidence base of sexual health in general practice is small with few examples of best practice. Several studies evaluated feasibility and effectiveness of offering chlamydia screening, and concluded that general practice is suitable and patients are happy to be offered screening or to discuss sexual health.(11,12) The general practice model of healthcare offers many opportunities in which to improve the sexual healthcare of patients of all ages beyond the traditional contraception and cervical screening consultations.
General practice alone will not avert the sexual health crisis; nevertheless nurses must recognise the important contribution they can make in improving sexual health and tackling associated inequalities. However, it is apparent that in spite of growing need, sexual health remains a "Cinderella" service in general practice.

Barriers to sexual healthcare
Department of Health guidance clearly states what health professionals should be doing to improve sexual health so why does it remain a marginalised service? Much is known about why sexual healthcare is not commonplace. Reasons identified in research for not discussing sexual health or offering screening include:

  • "It's a private matter."
  • "It's none of our business."(13)
  • "Sexual problems take up a long time and are best avoided."
  • "It's a can of worms."
  • "I just haven't got the time."(14)
  • "They will think we are perverts."
  •  "It just doesn't occur to me."(15)

These findings suggest that professionals are putting their own needs such as avoidance of embarrassment and time keeping before the health needs of patients. Time plays an important factor on the workload of general practice; however, it is unreasonable to use time as an excuse and is probably a façade for embarrassment, poor communication skills or lack of training.
Sexuality is a fundamental part of who we are as human beings and poor sexual health, whether it is erectile dysfunction, dyspareunia or unsafe sexual practice, can impact upon overall health and wellbeing. Hence it becomes clear that nurses have a duty of care for this aspect of health. Many nurses are dedicated to providing holistic healthcare, but this claim becomes untenable if there is a failure to consider the total health and wellbeing of patients.
Of particular significance in determining the barriers to sexual healthcare in general practice is the "QOF culture" (Quality and Outcomes Framework is a major part of the nGMS contract), which is criticised for encouraging focus on treatment processes rather than individualised care.(16) Much activity is centred on the maximisation of contract points, and it is a depressing fact that unless an intervention attracts money, it is not as vigorously pursued as those that do. The QOF is important in improving health, but it should not be at the expense of holistic care, and the strategy and NICE guidance firmly emphasise the need for sexual healthcare in general practice.

Overcoming the barriers
One interesting study examined attitudes of practice nurses to discussing sexual health needs.(17) Of 204 nurses offering cervical screening, 39% discussed sexual health during the appointment, and of 121 nurses offering family planning consultations, 65% discussed sexual health.
These results should not be generalised, but it is hard to understand how it is possible to discuss contraception or cervical screening yet ignore sexual health. Failure to address sexual health issues may possibly be a result of task-oriented rather than evidence-based and patient-centred care. It may also be due to the relatively recent emphasis on sexual health, which has come at a time of great change in general practice, and the lack of sexual health education during preregistration training.
It is not difficult to raise sexual health within such consultations; several key questions can determine risk factors or potential problems in males and females:

  • Have you had a change of partner in the past three months?
  • Have you had more than one partner within the past year?
  • Do you have any problems with sexual activity?

Similarly, an open approach can be taken in discussing sexual health with men with diabetes as approximately 60% of diabetic males over 60 will have erectile dysfunction, many of whom will not have the courage to mention the problem.(18)

  • Some men who take these medications may find that they have difficulties with erections, is this a problem for you?

This issue is not out of context in a diabetic or hypertensive clinic. It is a problem for a lot of men, and practice nurses specialising in chronic disease need to incorporate sexual health into their role.
It is thought that treating erectile dysfunction rather than depression could improve depression scores.(19) Nurses need to move on from thinking that patients will be offended if asked such questions, and perhaps crucially, from exploiting stereotypes when determining the sexual health needs of patients.

Education issues
What appears to be fundamental to the delivery of sexual healthcare in general practice is the need for training. Practice nurses who reported recent sexual health training were more likely to hold positive views when discussing sexual health and less likely to be embarrassed than nontrained colleagues, with 61% considering a lack of training to be a barrier to sexual healthcare.(17)
The findings were corroborated by a more recent survey of 1,000 practice nurses, which found that lack of training and lack of time still prevents proactive sexual health discussion.(20) However, the poor preparation for practice is not limited to sexual healthcare. A recent survey established that 30% of practice nurses had been asked to carry out QOF-related work, such as COPD, asthma or depression reviews, for which they had not received any training (with some refused study leave).(21)
Nurses want to improve the sexual health of clients; however, it would be unreasonable to expect nurses to provide sexual healthcare without appropriate training. Nevertheless sexual health training continues to be denied despite recommendations from the strategy that nurses receive training. Over 55% of students on the RCN Sexual Health Skills course (the majority from primary care) were self-funding according to the course director, indicating a determination to improve sexual health. Of course it is also plausible to suggest that many nurses do not know how to access training if it is not automatically offered to them, which could potentially result in ritualised or out-of-date and perhaps unsafe practice. A further implication of this is that nurses without sexual health training could perpetuate the barriers to sexual healthcare and continue to hold stereotypical views about the types of patient in need of effective sexual healthcare.

Moving forward
It would be impossible to suggest a quick fix solution for improving sexual health in general practice and it seems logical to aim for careful progression. The introduction of a call/recall system of screening for chlamydia could enable a greater sense of ownership of sexual health in general practice, destigmatise the infection and provide better training opportunities. It would also raise awareness of STIs among young adults who may not be accessing other settings such as family planning or outreach services, and highlight the need for regular sexual health checks.
Other strategies to raise the profile of sexual health within general practice could include assessment of erectile dysfunction in men with chronic disease as part of the QOF. However, practice nurses must not be limited by Department of Health or contract requirements and should be considering ways in which sexual health could be improved in everyday practice. Examples of consultations where sexual health could be raised are listed in Box 3; the list is not intended to be exhaustive and it is anticipated that nurses will think of alternative ways in which to implement sexual health discussion.
Nurses should know where to refer a patient for further advice or help if they are unable to deal with a problem as it may be the one occasion that a patient has the courage to raise the issue. It is also important to maintain an address book of useful resources that can be shared with patients to support the consultation (see Resources).

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Conclusion
There is more to sexual health than STIs or contraception, yet practice nurses have restricted access to training opportunities. Sexual health education is fundamental in enabling high-quality care as it is not a "see one, do one" skill; however, the biggest challenge at present is accessing funding and study leave. Practice nurses need to be resourceful in their approach to training and consider alternative sources of funding or study methods. Many education providers have responded to these problems with courses available online or via distance learning. Other short courses provide a brief overview of sexual health at a low cost and there are also free online modules that provide a useful starting point, such as the RCN's chlamydia educational initiative.
Practice nurses should not wait for sexual health to be handed down from any contract changes and can begin to make small steps to improve care. GPs and practice nurses have complementary skills and expertise and need to begin to work together on the issue. Consideration should be given to raise sexual health at practice meetings and establish the strengths and weaknesses of the team in delivering sexual healthcare.
Sexual health is important and it matters to patients. Putting sexual health on the general practice agenda will improve access to services, assist in meeting the aims of the National Strategy for Sexual Health and HIV, and enable patients to enjoy better sexual health.

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References

  1. Health Protection Agency. Diagnoses of selected STIs by Strategic Health Authority, country, sex and age group United Kingdom 1997 - 2006. London: HPA; 2007.
  2. Health Protection Agency. Testing times HIV and other sexually transmitted infections in the United Kingdom. London: HPA; 2007.
  3. Department of Health. The national strategy for sexual health and HIV. London: DH; 2001.
  4. Department of Health. Choosing health. London: DH; 2004.
  5. National Assembly for Wales. The strategic framework for promoting sexual health in Wales. Cardiff: Health Promotion Division NAW; 2000.
  6. The Scottish Parliament. Respect and responsibility: a strategy and action plan for improving sexual health. Edinburgh: Scottish Executive; 2005.
  7. Casell J, Brook MG, Mercer CH, et al. Treating sexually transmitted infections on primary care: a missed opportunity? Sex Trans Inf 2003;79:134-6.
  8. Cohen CE, Dawson SG, Theobald NJA, Desmond NM. Primary care and the National Strategy for Sexual Health and HIV: an evaluation of one primary care trust. Int J STD AIDS 2006;17:189-92.
  9. NICE. One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups. London: NICE; 2007.
  10. Dilloway M, Hildyard S. Female views on discussing sexual health. Br J Comm Nurs 1998;3:172-7.
  11. Harris DI. Implementation of chlamydia screening in a general practice setting: a 6-month pilot study. J Fam Plann Reprod Health Care 2005;31:109-12.
  12. Tobin C, Aggarwal R, Clarke J, Chown R, King D. Chlamydia trachomatis: opportunistic screening in primary care. Br J Gen Pract 2001;51:565-6.
  13. Evans DT. Speaking of sex: the need to dispel myths and overcome fears. Br J Nurs 2000;9:650-6.
  14. Gott M, Galena E, Hinchliff S, Elford H. "Opening a can of worms": GP and practice nurse barriers to talking about sexual health in primary care. Family Pract 2004;21:528-36.
  15. McNulty C, Freeman E, Bowen J, Shefras J, Fenton K. Barriers to opportunistic chlamydia testing in primary care. Br J Gen Pract 2004;504:508-14.
  16. Majeed A, Lester H, Bindman AB. Improving the quality of care with performance indicators. BMJ 2007;335:916-8.
  17. Stokes T, Mears J. Sexual health and the practice nurse: a survey of reported practice and attitudes. Br J Fam Plann 2000;26:89-92.
  18. Williams G, Pickup JC. Handbook of diabetes. 3rd ed. Oxford: Blackwell Publishing; 2004.
  19. Hackett G. Straight talking: bringing up erectile dysfunction. NiP 2006:31;65-7. Available from: http://www.nursinginpractice.com
  20. Durex. What do your colleagues think? Available from: http://www.durexchange.com/ncw/survey.php
  21. Healthcare Republic. Nurses working beyond competence. 14 December 2007. Available from: http://www.healthcarerepublic.com/news/GP/LatestNews/772906/Nurses-worki...

Resources
BASSH - British Association for Sexual Health & HIV
W: www.bashh.org

Department of Health - Sexual health policy and guidance
W: www.dh.gov.uk/en/Policyandguidance/
Healthandsocialcaretopics/Sexualhealth/index.htm

Department of Health - Delivering investment in general practice:
implementing the new GMS contract
W: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli...

Durex
W: www.durexchange.com

GenitoUrinary Nurses Association
W: www.guna.org.uk

Marie Stopes - Sexual health for overseas travel
W: www.mariestopes.org.uk/documents/travelguide.pdf

Medical Foundation for AIDS and Sexual Health.Recommended standards for sexual health
W: www.medfash.org.uk/publications/documents/Recommended_standards_for_sexu...

Men's Health Forum
W: www.menshealthforum.org.uk

National Association of Nurses for Contraception and Sexual Health
W: www.nancsh.org.uk

Rape Crisis
W: www.rapecrisis.org.uk

Royal College of Nursing Chlamydia Educational Initiative
W: www.rcn.org.uk/__data/assets/pdf_file/0006/78648/002513.pdf

Relate - relationship and sex therapy
W: www.relate.org.uk

RU Thinking? - Website for young adults with information about sex and local clinics
W: www.ruthinking.co.uk

University of Greenwich Sexual Health Skills Course (RCN accredited)
E: sexualhealthskills@
gre.ac.uk
T: 020 8331 8692

UK Nursing.net - website with free online training modules
W: www.uknursing.net

Forthcoming events
RCN Sexual Health Forum Conference and Exhibition 14 June 2008
W: http://www.rcn.org.uk/newsevents/event_details/rcn_events/event3575