Key learning points:
· Primary care nurses have a responsibility to address sexual health needs in practice
· Sexually transmitted infections are increasing in the UK
· Taking a sexual health history must include best practice guidance in consultation skills
This article explores how nurses in primary care settings continue to have difficulty in implementing sexual health discussions in normal practice. It identifies some of the real and perceived barriers in implementing this element of nursing care and also gives examples of how to integrate sexual health discussion into a consultation.
Sexually transmitted infections (STIs) are increasing in the UK. A Public Health England report1 identified 439,243 cases of STIs in 2014, with youngpeople under the age of 25 and men who have sex with men (gay and bisexual) being most at risk. In 2014 there were 6,000 new cases of HIV in the UK.1 STIs that present in primary care are many and varied. The presentation, management and treatment of all STIs in primary care can be found on the websites of the British Association for Sexual Health and HIV (BASH) and the Royal College of General Practitioners (RCGP) (see resources).2
Sexual healthcare is as important as the care of physical and mental health, yet many primary care nurses are ill prepared to address these needs.3 Learning experiences in pre-qualifying nurse education are sparse and opportunities to attend post-registration courses may be few unless the job role specifically relates to sexual health services.4 However, there is potential to approach sexual health topics opportunistically in primary care, if nurses feel confident to do so.
Reasons healthcare professionals do not talk about sex
The World Health Organisation (WHO)5 promotes nurses as the forefront of sexual health care delivery and other nursing authors suggest sexual health discussions are a fundamental component of nursing consultations,6,7 but many nurses remain uncomfortable to include this aspect of care in their general consultations.
Dyer and Nair8 conducted a systematic review of literature exploring healthcare professionals’ experience of discussing sexuality and sexual health issues with patients in the UK. This review identified various emerging themes that suggested why healthcare professionals did not feel able to incorporate sexual health discussions in routine practice. See if you can identify with any of those listed below:
· Fear of opening up a can of worms.
· Worry about causing offence.
· Concerns about the reactions of parents or staff.
· The patient should raise it first.
· Personal discomfort.
· Language barriers.
· Patient may sexualise the consultation.
· Concern about own knowledge and abilities.
· Access to training.
· Lack of recent experience.
· Time and resources.
· Availability of written information.
· Availability of policy guidance.
· Do not consider it their responsibility.
· Lack of communication between professionals.
· Not given ‘permission’ to raise the issue.
· Assume it is not an important issue.
· Lack of awareness of range of sexual issues.
· Assumptions about the cause of the sexual issue.
(Dyer and Nair, p2665)8.
However, it appears that the nurses who do feel comfortable discussing sexual health primarily do so when treatment and advice are needed following a diagnosis such as an STI or menopausal symptoms.9 Personal perceptions and lack of knowledge and training affect how nurses perceive the importance of inclusion of sexual health discussion in their practice in primary care – therefore patients’ sexual health needs are not being met.7
The role of the primary care nurse in taking a sexual history
Your role in primary care will influence the type of consultation you are able to perform. For example, as a school nurse you may be restricted to certain times and environments. Practice nurses may be able to incorporate opportunistic discussions. Time and resources may be a potential barrier, although sexual health discussion should always be seen as a core component of any consultation and education and training needs should be discussed at your appraisal.
As identified above, you may have many perceptions of what a sexual health discussion should or shouldn’t be and how you view STIs. It is important to reflect on your own beliefs, attitudes and practice to understand and acknowledge them. Patients may be more uncomfortable than you are and may find it difficult to initialise the conversation due to a perceived moral stigma, both in young and older age groups10.
BASH 2013 guidelines for consultations requiring sexual history taking can be accessed here http://www.bashh.org/documents/Sexual%20History%20Guidelines%202013%20final.pdf.11 Although this guidance is primarily aimed at professionals providing sexual health care services, it is still useful for all nurses in primary care. It discusses areas of confidentiality, communication, components of a sexual history, symptom review, previous STIs, diagnosis and testing, contraceptive and reproductive health history, risk assessment, closing the sexual history and documentation. If this is not within your scope, you should draw on the elements most relevant to your knowledge, understanding and field of practice. It is important to know when to refer to other services and have contact numbers of appropriate services, including interpreter services, social services and safeguarding leads.
A fundamental factor is how you conduct the consultation as this can affect whether the patient takes on board any advice given, and whether they feel able to return for future discussions. The principles apply to all nursing consultations, but the following are particular areas to consider for a sexual health consultation:
· Confidentiality and privacy – even to those under 16 years of age if they are competent according to Fraser guidelines12, and for each patient if a partner is a member of the same practice.
· Non-verbal skills – both yours and the patient’s. Avoid appearing shocked or judgmental. Body language is imperative; ensure you appear welcoming. Have a relaxed seating position and let the patient see that you are listening by nodding your head and recapping.
· Give a friendly, welcoming greeting. Introduce yourself and ask ‘how can I help?’. Advise the patient you may need to ask some very personal questions to assist you in the consultation, and ask if they agree to this.
· Provide patient information leaflets and signpost to credible websites for further information. NHS Choices website http://www.nhs.uk/chq/pages/category.aspx?CategoryID=118is an effective tool to assist in overcoming language barriers as it has the translate option.
· Use demonstration models where necessary (eg when teaching correct use of condoms).
· Always be aware of potential safeguarding issues for all ages, particularly patients at risk of FGM, domestic violence, child sexual exploitation, patients with learning disabilities and mental capacity issues. Ensure you are aware of the local safeguarding policy and escalation and your surgery’s reporting mechanism.
The case study demonstrates components of a sexual health history taken in a primary care setting:
Female aged 21, presents with a history of vaginal discharge, requesting treatment for ‘thrush’.
To competently assess this patient, a sexual health risk assessment needs to be undertaken. This will provide direction and help you decide whether to treat empirically or to undertake a genital examination. Women who are at low risk for STIs can be treated without examination. Those with persistent vaginal discharge should be examined to exclude pathology.
Factors to include in the consultation and rationale
· Onset and duration of symptoms – to enable consideration of differential diagnosis.
· Characteristics of discharge – colour, odour, consistency – to clarify what is normal for the patient.
· Any associated symptoms (itching, dysuria, postcoital bleeding, intermenstrual bleeding, pelvic pain, deep dyspareunia) to identify if referral is required.
· Current contraception – hormonal methods of contraception are known to increase vaginal discharge.
· Condom use – to assist the risk assessment for STIs.
· First day of last menstrual period – to exclude pregnancy.
· Date of last episode of sex – to identify incubation periods for infection. In the under 25s the most common STI is chlamydia which has a two-week incubation period.
· Does she have a current partner? If yes, is it male or female? This will assist with risk assessment.
· Apart from her current partner, is she having sex with anyone else – again, this will assist with risk assessment.
· How many sexual partners has she had in the past six months? For risk assessment.
· History of previous STIs and participation in National Chlamydia Screening Programme – to assist with risk assessment
· Co morbidities including epilepsy, diabetes, whether she is immunocompromised – to explore non sexual reasons for discharge.
· Current medication – to exclude drug interactions.
· Exclude possibility of non-infective causes including retained tampons, condoms, foreign bodies, cervical ectopy, polyps or dermatological disease.
A comprehensive sexual health history was taken and provided the following information.
· Patient was symptomatic for two weeks with a white-grey discharge. Only when asked about its odour did she confirm it had a ‘fishy smell’. She reported no other symptoms. When asked about hygiene and bathing she said she performed vaginal douching. This demonstrates how effective communication skills and appropriate questions will often provide further depth.
· Her current contraception was a subdermal contraceptive implant inserted 10 months previously, and she reported no condom use.
· She had amenorrhea – a common side-effect with this contraceptive method.
· Her last episode of sex was two weeks ago with her current male partner. She has no other sexual partners. She has had this one sexual partner in the past six months.
· She had no previous episodes of infection and no comorbidities or medication, and no reports of possibility of foreign objects.
· She had a negative chlamydia test result 12 months ago when she was with her previous sexual partner.
Following discussion and risk assessment, the patient was offered the option to perform a self-taken vulvovaginal swab behind a screen, which she accepted. This is an appropriate sampling method and is more acceptable to patients than a speculum examination. Following explanation of how to perform the test, the patient reported she found it a simple procedure and felt comfortable in undertaking it. An important reminder at this point is to ensure you are familiar with the diagnostic equipment your local laboratory uses and to check expiry dates of consumables prior to use, as out-of-date swabs will be discarded and mean the patient has to repeat the test and will delay treatment.
The opportunity was taken to discuss safer sexual practices with the patient and she was reminded of the STI risks when having sex without condoms. The patient stated that she had not even considered she may have been exposed to an STI. She was focused on preventing pregnancy. Even when she had a new partner she had simply thought she was ‘fine’ as she had the contraceptive implant.
The patient’s hygiene practices were discussed and addressed and she was advised to cease douching as this removes the healthy bacteria from the vagina and disturbs the pH balance, giving rise to opportunistic infections. She was encouraged to avoid using highly perfumed soaps and bathing products.
Microscopy identified clue cells on examination and she was diagnosed with bacterial vaginosis. This demonstrates the importance of undertaking an effective consultation instead of responding to a request for treatment of ‘thrush’, which in this case would have been inappropriate.
Knowledge and understanding of common STIs, their diagnosis and treatment, are essential for primary care nurses to address sexual health needs. Awareness of current guidelines and when to refer to specialist services will help to ensure this area of practice is considered alongside physical and mental health, to meet the needs of all communities.
British Association for Sexual Health and HIV – www.bashh.org/guidelines
Royal College of General Practitioners – www.rcgp.org
1. Public Health England. Health Protection Report (2015) Infection report, HIV – STI’s, Sexually transmitted infections and Chlamydia screening in England 2014. gov.uk/government/uploads/system/uploads/attachment_data/file/437433/hpr2215_STI_NCSP_v6.pdf (accessed 7 June 2016).
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5. World Health Organisation. Sexual Health, 2012. who.int/reproductivehealth/topics/gender_rights/sexual_health/en/(accessed 7 June 2016).
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11.The British Association of Sexual Health and HIV (BASH 2013) UK national guidelines for consultations requiring sexual history taking. bashh.org/documents/Sexual%20History%20Guidelines%202013%20final.pdf.(accessed10 June 2016).
12.British and Irish Legal Information Institute. Gillick v West Norfolk & Wisbech Area Health Authority, UKHL 7, 17 October 1985.