TM: Sensitive Histories in General Practice (ii)
Irish Study of Sexual Health + Relationships (ISSHR)
increasing liberal attitudes towards sex
strong association between education, social class + liberal attitudes (abortion, homosexuality, sex before marriage)
misinfo regarding chlamydia, emergency contraception, AIDS
age of 1st SI: 19 in females, 18 in males
low rate of contraception use in younger age groups + lower socioeconomic groups
reasons for not using contraception
non-availability
lack of planning
alcohol + drug use
most likely to have STIs if
male
aged 25-34
casual relationship / not in a relationship
1st SI younger than 17
younger people used condoms, those in settled relationships used OCP
thought it was no longer needed (35-44 y/o)
Taking a sexual Hx
both patient + Dr can be uneasy
emotional, emotive, embarrassing, moral + legal issues
presenting complaints
STIs
genital complaints
recurrent UTIs
men usually don't get UTIs so rule out STIs 1st
sexual dysfunction
decreased libido
anorgasmia
impotence
premature ejaculation
fertility issues
beware of the hidden agenda: frequent/repeat attendees
NB: raising the issue @ the appropriate time
specific consultations - contraception
emergency contraception
dysuria
vaginal discharge
in house advertising of services (shows this is a safe environment for discussing these things)
routine questionnaire for 1st time new patients/adolescents/well man/well women clinics - ticking boxings easier
as followups for other medical conditions: e.g. diabetes/hypertension can have effects of sexual health
ensure confidentiality
educate re safer sex
support the young sexually active
informed consent needed for tests
chaperone issues
protocol for pre-HIV testing, results, tx + referral
contact tracing
insurance issues
Qs
name
address
DOB
relationship status
PMH + surgical hx
obstetrical hx
have you any children?
were you ever pregnant?
any miscarriages?
any terminations?
what age did you 1st become sexually active?
when were you last sexually active?
what do you mean be sexually active?
oral
vaginal
anal (increases STI risk)
giving or receiving
sexual practice info NB as tells us where to take samples from
was that with a man or woman?
do you only have sex with men/women?
rude to ask outright if they're straight or gay
ask permission: "do you mind if I ask..." then explain the reasons
contraception
previous STI
menstrual hx
smear hx
drug allergies
Hx of IVDU - self or partner
ever paid for sex
partner's ethnicity (some areas of work have high STI prevalence)
be professional + acknowledge many people are uncomfortable discussing sex
be aware of your own limitations - fall back on standard limitations if it helps
Underage patients
16+ can give consent for surgical/medical/dental tx (incl contraception, sexual health advice + interventions - although law does not specifically state this)
medical notes can be legally requested by the parent(s) of patients under 18 (no promise of confidentiality)
only 18+ can legally sign a consent form - so no invasive procedures (implants/IUD) without parental consent
age of consent = 17
any sexual relationship when 1+ parties are underage is illegal - but may not necessarily be child abuse due to exceptions... (all of the criteria must be fulfilled)
Drs are mandated reporters (legally required to report any suspicion of child abuse to Tusla)
the underage person is 15+
the age difference is no more than 24 months
there is no difference in their maturity/capacity to consent
the relationship doesn't involve intimidation or exploitation
the underage person clearly states they don't want the info to be reported to Tusla
i.e. you do not have to report consensual sexual activity between older teenagers
UK Fraser Guidelines
A "Gillick Competent" young person...
has sufficient maturity to understand the moral, social + emotional implications of tx
cannot be persuaded to inform parents
likely to have sex
tx is the best option for them