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STIs: tackling the taboos with teenagers

Jan Freer
RGN
Lead Practice Nurse
Imperial Medical Practice
Devon

Sexual behaviour is a biological function yet its expressive nature is socially influenced. Changing attitudes and lifestyles in the UK have contributed to a lowering of the age of sexual activity and reduced the likelihood of a single lifetime partner.(1)
Young sexually active women are particularly vulnerable; the risk of unwanted pregnancy and sexually transmitted infection (STI) is high. Increasing STI rates in 16-24-year-olds are a major public health concern. Exposure to sexual risk increases in concurrent and serial relationships commonly practised by young people.
Although condom use reduces the risk of STIs and pregnancy, adolescents often lack the confidence or negotiation skills for effective use. Inadequacies within socioeconomic status, biological responses, healthcare provision and behaviour can be predictors of early sexual activity and subsequent STI acquisition.
Morbidity associated with STI includes infertility, adverse pregnancy outcomes and increased risk of cervical or ovarian cancer.(2)
The Sexual Health Strategy aims to reduce the transmission of STIs and human immunodeficiency virus (HIV) through development of local evidence-based services for effective prevention.(3)

STIs and the adolescent
STIs can cause immense emotional and physical distress. Only those most prevalent will be discussed in this article. Evidence-based clinical effectiveness guidelines published by the British Association for Sexual Health and HIV (BASHH) are an excellent resource for the definition and management of sexual health problems.(4)
Although treatment within primary care can be effective, referral to specialist genitourinary medicine (GUM) services must ensue unless absolute clarity regarding diagnosis and treatment is achieved.

Chlamydia
The suggested incidence of Chlamydia trachomatis is between 3% and 10% of the population. Eighty per cent of female infections are asymptomatic. Symptoms include dyspareunia (painful sexual intercourse), intermenstrual or postcoital bleeding, pelvic pain and purulent vaginal discharge. Chlamydia is a major cause of pelvic inflammatory disease (PID) as a consequence of ascending reproductive tract infection.
Complications include infertility, ectopic pregnancy and chronic pelvic pain. High-risk indicators include being below 25, absence of barrier contraceptive use and numerous partners. It is envisaged that the enthusiasm and skills of practice nurses will contribute to the success of national chlamydia screening for sexually active young people.(5)

Gonorrhoea
Caused by the organism Neisseria gonorrhoeae, gonorrhoea is sexually transmitted between mucous membranes in the genitalia, rectum or throat. Up to 50% of infections in women are asymptomatic, but patients may present with mucopurulent vaginal discharge, contact vaginal bleeding, lower abdominal tenderness or dysuria (pain on passing urine). Complications include PID and vertical transmission causing neonatal blindness.

Trichomonas vaginalis
The protozoan infection Trichomonas vaginalis is sexually transmitted via the urethra or vagina. It is asymptomatic in 10-50% of females. Symptoms include vulvovaginitis with a vaginal discharge that is frothy and yellow in 10-30% of cases. Associated with preterm birth and low birthweight, it may also facilitate HIV transmission.

Syphilis
Syphilis can be acquired as a primary infection or congenitally. It is sexually transmitted between mucous membranes in the genitalia, rectum or throat. A discrete transitory ulcer at the site of infection is an early symptom.
Early treatment is essential to prevent chronic devastating complications affecting neurological and cardiovascular systems. Syphilis may also facilitate HIV transmission.

Genital warts
Genital warts are caused by the sexually transmitted human papillomavirus (HPV). Often in clusters and of variable dimensions, warts necessitate cosmetic treatment. HPV is strongly associated with an increased risk of cervical cancer.

Genital herpes
Caused by the herpes simplex virus, transmission can be through genital or orogenital contact. Characteristic genital blisters are extremely painful. These may be accompanied by fever and malaise. Once acquired, genital warts and herpes episodes are usually recurrent. Condoms are unlikely to prevent transmission since the entire genital surface is susceptible.(4)

Tackling the problem with teenagers
GUM services are often inaccessible to adolescents as travelling distance may be inhibitive and waiting times are long. The familiarity of general practice may help adolescents to seek advice for symptoms or if they consider themselves to be taking risks. Posters in the surgery waiting room offering teenagers nonjudgemental, confidential advice regarding STIs and contraception can encourage attendance. A teenage health promotion pack can be given when attending for final childhood immunisations, supported by an open invitation to discuss health issues. This pack should include literature freely available from NHS health promotion centres about smoking, drugs, alcohol and sexual issues.
Practice nurses are considered positive and adept at providing contraceptive advice and education, feeling comfortable with women's and adolescents' health issues. Specialist training such as the RCN's Sexual Health Skills distance learning course or Sexually Transmitted Infection Foundation (STIF) course run by BASHH can equip nurses with the knowledge, skills and confidence to educate and screen sexually active adolescents. New opportunities will enable appropriately skilled nurses to provide accredited specialist sexual health services in primary care as locally enhanced services set up by primary care trusts.(5) Accountability and clinical governance must guide clinicians during consultations. Practice nurses must be competent before providing comprehensive management of sexual health issues. If provision of advice is the only scope of clinical expertise, referral to a more experienced colleague or GUM service will ensure that opportunities to screen and treat are seized.

Sexual history and risk assessment
Sexual health screening is standardised regardless of being symptomatic or asymptomatic. Sexually active adolescents should be encouraged to attend for screening. Diagnostic success is not reliant upon clinical presentation; risk assessment ensures appropriate screening with effective treatment and education. Clinical history taking identifies symptoms or concerns, and should include questioning about symptom onset, fever, dyspareunia, unusual bleeding and description of discharge.(4) Acute pelvic pain necessitates immediate medical referral to exclude PID or ectopic pregnancy.
Competent sexual history taking and risk assessment is the first stage in effecting appropriate management. Seeking sexual health advice may cause feelings of shame or humiliation. Adolescents' trust must be earned using honesty, empathy and listening skills. Warmth of greeting, nonjudgmental attitude and feeling comfortable with discussing sexuality encourage honesty and constructive responses to open questions. Confidentiality and privacy must be assured. Effective communication skills clarify information if patients are vague, euphemistic or colloquial.(6,7)
Social, epidemiological, biological and behavioural factors that facilitate and increase the risk of STI acquisition influence structure and content of sexual history taking.(7) Homosexuality, bisexuality, specific sexual practices, intravenous drug use, sex work, sexual abuse and ethnicity are high-risk indicators for STIs. Awareness of these indicators in previous or current partners is also relevant. Based on factors influencing STI acquisition with the aim of providing holistic healthcare, a structured sexual history should be documented, and should include questions regarding smoking, alcohol and drugs, as well as overseas travel, contraception, marital status, previous STIs, sexual orientation and sexual practices.(6) It is also important to discuss sexual partners, including age of current partner and number and sexual orientation of previous partners.
By the age of 16, approximately 25% of teens are sexually active in the UK. The Sex Offences Act 2003 recognises the needs of sexually active adolescents under the age of 16. Fraser guidelines support clinicians in providing competent minors with confidential sexual health advice to reduce associated risks. Suspicions of sexual abuse, exploitation or disparity of age must always be explored according to child protection guidelines.(8) Disclosure of sexual behaviour and practices is pivotal to risk assessment. Human sexual practices can be as diverse as ingenuity permits, producing the potential for enhanced sexual satisfaction. Diversity may decrease or increase risk. Heterosexual sex is commonly penetrative. Safer nonpenetrative sexual activity is rarely practised separately from intercourse.  Anal sex is allegedly practised by 13% of women. Oral sex is commonly practised by young people. These practices and male bisexuality expose young women to a wider range of STIs.(1) Sexual activity increases during holiday seasons, and international travel produces exposure to new sexual networks.

Examination and tests
Since STIs can frequently coexist, comprehensive screening must be offered. This necessitates physical examination and diagnostic tests.(4) Physical examination of adolescents requires an exceptionally sensitive approach since they are often unaccustomed and unprepared for this invasion of privacy. The intimate nature of gynaecological examination may trigger memories of sexual abuse, resulting in emotional trauma. Cultural beliefs and physical or learning disabilities must be respected. Adherence to professional guidelines is imperative. In the absence of this, regardless of gender, clinicians justifiably risk accusations of assault or misconduct. Informed consent must be obtained, ensuring that the patient has a full understanding. A chaperone should be offered, and procedures must be documented. Examinations should be appropriate, skilled and gentle, respecting privacy and dignity. Clinicians must be prepared to abort the procedure and reconsider options at the patient's request.(9)
High vaginal and endocervical swab specimens must be expertly obtained; inadequate swab taking reduces diagnosis and treatment rates. A single male urethral swab can be accompanied by a first-catch urine specimen (chlamydia testing). Diagnosis of genital warts is confirmed visually, and genital herpes by viral swab.(4)
Serological screening for syphilis and viral hepatitis should be offered following risk assessment. HIV testing should be offered regardless of risk. The devastating impact of HIV warrants opportunistic screening, and normalisation of HIV testing helps reduce stigma.(3) Pretest discussion can include the information that prognosis is improving. Before arranging a date to convey results to patients, opportunistic psychological and educational support should be provided.(7)
Laboratory analysis of specimens delays diagnosis. Failure to return for results risks failure to treat and educate. Successful communication of results is not only a duty of care, it is a public health directive. Maintaining confidentiality is essential. If reattendance is doubtful, coded mobile phone text messages can be appealing.(4)
BASHH clinical effectiveness guidelines provide comprehensive directives for STI treatment. BASHH patient group directions for nurse administration may be agreed locally.(7) Young people tend to be highly sexually active, and abstinence is implausible.(1) Single doses or regimens with high efficacy and acceptable tolerance will encourage concordance and expedite cure.

Psychological and educational support
Stigmatisation, often associated with STIs, can result in social isolation and reduced opportunities. Raised public awareness of STIs with increased accessibility of services within primary care may effectively reduce stigma. The severe psychological impact of some STIs may require concerted efforts to rebuild sexual confidence.(2)
If results are normal yet symptoms persist, medical referral is essential. Regardless of results, repeated psychological and educational support builds on previous information. Multiple risk-taking behaviours frequently coexist with STIs.(4) Advice can be based on sexual history and lifestyle information. Positive attitudes, values and self-esteem should be promoted. Effects of STIs and treatment regimens should be explained and understood. The responsibility of identifying partners for screening and treatment of STIs must be discussed and information on modifying risk-taking lifestyle provided.(7) Skills for effective condom and contraceptive use should be developed. Sexual repertoire adaptation not only may reduce risk but also can  enhance sexual satisfaction.
Sexual activity is inextricably associated with not only infection but also contraception. Contraception empowers women by providing them with the sexual confidence of fertility control. All sexual health interventions should incorporate contraceptive aspects.
Partner notification is a public health responsibility. Without treatment, sexual networks continue to harbour STIs, resulting in inequity for high-risk groups. GUM services offer an excellent system for partner notification. If adolescents are reluctant to advise current and previous partners to seek screening and treatment, they should be encouraged to ask local GUM services to contact them anonymously. Clinicians must promote the philosophy of caring for partners' health.

Conclusion
The outset of reproductive life must be supported by services that provide preventive education and encourage treatment-seeking behaviour. Exceptional sensitivity and expertise are essential requisites for sexual history taking and examination of adolescents. Building trust and rapport produces effective outcomes and encourages follow-up attendances. Clinicians should only undertake new roles if they can learn or demonstrate appropriate attitudes and commitment. Practice nurses possess these essential qualities. New training opportunities should be embraced to enable them to improve the sexual and reproductive health of our adolescent population.

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References

  1. Wellings F. Sexuality, sexual behaviour and sexual health. In: Kubba A, Sanfilippo J, Hampton N, editors. Contraception and office gynecology; choices in reproductive healthcare. London: Harcourt Publishers; 1999:3-9.
  2. Sexually transmitted infections in the UK; new episodes seen at genitourinary medicine clinics 1995-2000. London: PHLS, DHSS & PS and the Scottish ISD(D)5 Collaborative Group; 2001
  3. Department of Health. The national strategy for sexual health and HIV. London: DH; 2001.
  4. BASHH. Clinical effectiveness guidelines. Available from  http://www.bashh.org/guidelines.asp
  5. DH Sexual Health Team. Integrating the national strategy for sexual health and HIV with primary medical care contracting. London: DH; 2005.
  6. Tomlinson J. BMJ 1998; 317:1573-6.
  7. WHO. Sexually transmitted infections; issues in adolescent health and development. Geneva: WHO; 2004.
  8. Department of Health. Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health. London: HMSO; 2004.
  9. RCOG. Gynaecological examination: guidelines for specialist practice. London:RCOG; 2002.

Resources
Sexually Transmitted Infection Foundation (STIF) course
W:www.bashh.org/education/stif_course/index.asp
RCN Sexual Health Skills course
W:www.rcn.org.uk/resources/sexual health/index.php
BASHH
W:www.bashh.org.